MEDICARE: JOSEPH W VICKROY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	90183895-1205	UT

General Provider Information

NPI Number	:	1104818442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH W VICKROY M.D.

Provider Business Mailing Address
First Line	:	2708 GALLIVAN LOOP
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84060-7074
Country	:	US
Telephone Number	:	801-599-1750
Fax Number	:	801-293-6828

Provider Business Practice Location Address
First Line	:	1200 E 3900 S
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84124-1300
Country	:	US
Telephone Number	:	801-294-6907
Fax Number	:	801-294-6917

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	12/16/2022

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