Healthcare Provider Details

I. General information

NPI: 1245890524
Provider Name (Legal Business Name): CONOR MORAN VICKERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 COTTMAN AVE
PHILADELPHIA PA
19111-2434
US

IV. Provider business mailing address

3500 N BROAD ST RM 1A
PHILADELPHIA PA
19140-4106
US

V. Phone/Fax

Practice location:
  • Phone: 215-728-2191
  • Fax: 215-214-3992
Mailing address:
  • Phone: 215-707-2433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD480075
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: