Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0200X | Radiology | CH0001488 | FL |
Y | 213ER0200X | Radiology | CH0001488 | FL |
NPI | 1568486777 |
---|---|
Provider Name | Dr. Edward Dee Vickers SR. |
First Address | Clewiston, FL 33440-3411 |
Second Address | Clewiston, FL 33440-3411 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2006 |
Last Update Date | 03/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
380116100 | (05) | FL |
89525 | BLUE CROSS/ BLUE SHIELD (01) | FL |
T56245 | (02) | FL |