Healthcare Provider Details

I. General information

NPI: 1336364793
Provider Name (Legal Business Name): JOHN DAVID VICKERY IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 CALUMET PKWY BUILDING F, SUITE 201
NEWNAN GA
30263-6734
US

IV. Provider business mailing address

690 DALLAS HWY SUITE 101
VILLA RICA GA
30180-1264
US

V. Phone/Fax

Practice location:
  • Phone: 770-683-4050
  • Fax:
Mailing address:
  • Phone: 770-459-0620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number44948
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number67624
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number44948
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number67624
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: