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General NPI Number Information
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NPI Number | 1770147969
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Entity Type | Individual
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Provider Name | JUSTIN WAYDE VICKERY MD
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Gender | Male
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Dates
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Enumeration Date | 04/24/2019
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Last Update Date | 08/01/2025
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Provider Practice Location Address
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Address Line | 10861 183A TOLL RD STE 1200
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City | LEANDER
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State | TX
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Zip | 78641-1257
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Country | US
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Telephone | 512-439-1009
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Fax | 512-439-1145
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Provider Business Mailing Address
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Address Line | 4700 SETON CENTER PKWY STE 115
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City | AUSTIN
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State | TX
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Zip | 78759-5753
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Country | US
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Telephone |
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Fax |
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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 | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | V7311
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207XS0117X
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Taxonomy Name | Orthopaedic Surgery of the Spine Physician
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License Number | V7311
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License Number State | TX
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