Healthcare Provider Details

I. General information

NPI: 1932802816
Provider Name (Legal Business Name): SUSAN JILL VICKERY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE
TULSA OK
74136-1902
US

IV. Provider business mailing address

4600 INVERNESS RUN DR
JONESBORO AR
72405-8056
US

V. Phone/Fax

Practice location:
  • Phone: 918-502-1900
  • Fax: 918-494-6303
Mailing address:
  • Phone: 870-476-9905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number8597
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: