MEDICARE: WILLIAM T VICARY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	G30952	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G30952	OTHER	CA	BLUE CROSS
2	G30952	OTHER		AETNA
3	G30952	OTHER	CA	HEALTHNET
4	G30952	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1396876678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM T VICARY M.D.

Provider Business Mailing Address
First Line	:	3575 CAHUENGA BLVD W
Second Line	:	SUITE 300
City	:	LOS ANGELES
State	:	CA
Zip	:	90068-1342
Country	:	US
Telephone Number	:	323-876-9133
Fax Number	:	323-876-4716

Provider Business Practice Location Address
First Line	:	3575 CAHUENGA BLVD WEST
Second Line	:	SUITE 300
City	:	LOS ANGELES
State	:	CA
Zip	:	90068-1342
Country	:	US
Telephone Number	:	323-876-9133
Fax Number	:	323-876-4716

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	10/11/2013

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