Provider Demographics
NPI:1912675547
Name:VICKERS, DAMON
Entity Type:Individual
Prefix:MR
First Name:DAMON
Middle Name:
Last Name:VICKERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 EMPIRE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-2810
Mailing Address - Country:US
Mailing Address - Phone:631-450-6216
Mailing Address - Fax:
Practice Address - Street 1:619 EMPIRE AVE
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-2810
Practice Address - Country:US
Practice Address - Phone:631-450-6216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program