Provider Demographics
NPI:1932251253
Name:VICKS, SHERELL DENISE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHERELL
Middle Name:DENISE
Last Name:VICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 HILLANDALE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-1884
Mailing Address - Country:US
Mailing Address - Phone:770-808-0092
Mailing Address - Fax:770-808-0380
Practice Address - Street 1:5910 HILLANDALE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-1884
Practice Address - Country:US
Practice Address - Phone:770-808-0092
Practice Address - Fax:770-808-0380
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034265207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00641935CMedicaid
GA11BDTLMMedicare ID - Type Unspecified
GA00641935CMedicaid