Healthcare Provider Details

I. General information

NPI: 1215964754
Provider Name (Legal Business Name): SELWYN MAURICE VICKERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE STE M-110
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

1275 YORK AVE STE M-110
NEW YORK NY
10065-6007
US

V. Phone/Fax

Practice location:
  • Phone: 212-639-6561
  • Fax: 212-717-3299
Mailing address:
  • Phone: 212-639-6561
  • Fax: 212-717-3299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number49253
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number18186
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number18186
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: