Healthcare Provider Details

I. General information

NPI: 1104818442
Provider Name (Legal Business Name): JOSEPH W VICKROY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 12/16/2022
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E 3900 S
SLC UT
84124-1300
US

IV. Provider business mailing address

2708 GALLIVAN LOOP
PARK CITY UT
84060-7074
US

V. Phone/Fax

Practice location:
  • Phone: 801-294-6907
  • Fax: 801-294-6917
Mailing address:
  • Phone: 801-599-1750
  • Fax: 801-293-6828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number90183895-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: