Healthcare Provider Details

I. General information

NPI: 1649381864
Provider Name (Legal Business Name): MARVIN HABER VICKERS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 BREAKWATER DR
KNOXVILLE TN
37922-5678
US

IV. Provider business mailing address

2227 BREAKWATER DR
KNOXVILLE TN
37922-5678
US

V. Phone/Fax

Practice location:
  • Phone: 865-675-2890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD9229
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD9229
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: