Healthcare Provider Details

I. General information

NPI: 1033137666
Provider Name (Legal Business Name): JOHN C VICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 REYNOLDS ST SUITE 100
MONROE NC
28112-4376
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-289-5443
  • Fax: 704-283-7655
Mailing address:
  • Phone: 704-289-5443
  • Fax: 704-283-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21888
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: