Provider Demographics
NPI:1063529105
Name:VICKSTROM, DOUGLAS EARL (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:EARL
Last Name:VICKSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25665 VALLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7315
Mailing Address - Country:US
Mailing Address - Phone:563-332-4172
Mailing Address - Fax:563-332-4172
Practice Address - Street 1:2979 VICTORIA ST
Practice Address - Street 2:VA OPT CLINIC
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722
Practice Address - Country:US
Practice Address - Phone:563-332-8528
Practice Address - Fax:563-332-9331
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A01279Medicare UPIN