Healthcare Provider Details

I. General information

NPI: 1609919711
Provider Name (Legal Business Name): LAWRENCE ALAN VICKMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 BAYSHORE BLVD SUITE E
TAMPA FL
33611-4183
US

IV. Provider business mailing address

5323 BAYSHORE BLVD SUITE E
TAMPA FL
33611-4183
US

V. Phone/Fax

Practice location:
  • Phone: 813-805-0388
  • Fax: 813-805-0390
Mailing address:
  • Phone: 813-805-0388
  • Fax: 813-805-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME 84580
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License NumberME-84580
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: