Healthcare Provider Details

I. General information

NPI: 1043385123
Provider Name (Legal Business Name): DOUGLAS TODD VICK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 SUNSET BLVD N STE A
SUNSET BEACH NC
28468-4340
US

IV. Provider business mailing address

PO BOX 2123
BRYSON CITY NC
28713-5123
US

V. Phone/Fax

Practice location:
  • Phone: 910-663-2273
  • Fax: 910-663-4050
Mailing address:
  • Phone: 910-490-0490
  • Fax: 828-538-4441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA555
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102728
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: