MEDICARE: CELESTE MICHELLE VICKERY D.O.

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	207Q00000X	Family Medicine Physician	OS19786	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780211821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CELESTE MICHELLE VICKERY D.O.

Provider Business Mailing Address
First Line	:	1061 MEDICAL CENTER DR STE 102
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8225
Country	:	US
Telephone Number	:	386-917-7668
Fax Number	:	386-456-1206

Provider Business Practice Location Address
First Line	:	1061 MEDICAL CENTER DR STE 102
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8225
Country	:	US
Telephone Number	:	386-917-7668
Fax Number	:	386-456-1206

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

Provider Enumeration Date	:	03/26/2020
Last Update Date	:	09/19/2023

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