Healthcare Provider Details

I. General information

NPI: 1982875050
Provider Name (Legal Business Name): DOUGLAS E. VICK, DO M. TAMARIN VICK, DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 CROSSFIELD DR
VERSAILLES KY
40383-1468
US

IV. Provider business mailing address

208 CROSSFIELD DR
VERSAILLES KY
40383-1468
US

V. Phone/Fax

Practice location:
  • Phone: 859-873-8044
  • Fax: 859-873-8045
Mailing address:
  • Phone: 859-873-8044
  • Fax: 859-873-8045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number02382
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02382
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number02383
License Number StateKY

VIII. Authorized Official

Name: MARY TAMARIN VICK
Title or Position: PRACTITIONER
Credential: D.O.
Phone: 859-873-8044