Healthcare Provider Details

I. General information

NPI: 1659596112
Provider Name (Legal Business Name): MARY TAMARIN VICK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY TAMARIN RING DO

II. Dates (important events)

Enumeration Date: 04/17/2007
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 Code208D00000X
TaxonomyGeneral Practice Physician
License Number02383
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: