Provider Demographics
NPI:1912986266
Name:VICKERS, GARY WILBUR (OD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:WILBUR
Last Name:VICKERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 MOUNT SHASTA WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-6213
Mailing Address - Country:US
Mailing Address - Phone:502-425-5839
Mailing Address - Fax:
Practice Address - Street 1:3301 MOUNT SHASTA WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6213
Practice Address - Country:US
Practice Address - Phone:502-425-5839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-14
Last Update Date:2011-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY775DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9160101Medicare ID - Type Unspecified