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General NPI Number Information
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NPI Number | 1043385123
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Entity Type | Individual
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Provider Name | DOUGLAS TODD VICK PA-C
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Gender | Male
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Dates
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Enumeration Date | 11/22/2006
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 4736 HIGHWAY 17 BYP S
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City | MYRTLE BEACH
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State | SC
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Zip | 29588-5616
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Country | US
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Telephone | 843-213-2039
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Fax | 843-293-2454
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Provider Business Mailing Address
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Address Line | 4736 HIGHWAY 17 BYP S
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City | MYRTLE BEACH
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State | SC
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Zip | 29588-5616
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Country | US
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Telephone | 843-213-2039
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Fax | 843-293-2454
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 102728
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA555
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License Number State | SC
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