Provider Demographics
NPI:1952377228
Name:VICKERY, CHRISTOPHER L (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:L
Last Name:VICKERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 N BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3000
Mailing Address - Country:US
Mailing Address - Phone:706-868-5676
Mailing Address - Fax:706-722-2824
Practice Address - Street 1:340 N BELAIR RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3000
Practice Address - Country:US
Practice Address - Phone:706-868-5676
Practice Address - Fax:706-722-2824
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034487207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000724006GMedicaid
5446256OtherAETNA
GA940261OtherBLUE CROSS
157315300OtherEMPLOYMENT STANDARD
GAP00201658OtherMEDICARE RAILROAD
8202549OtherCIGNA
8202549OtherCIGNA
GA000724006GMedicaid