Provider Demographics
NPI:1073503165
Name:VICK, MICHAEL L
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:VICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 W MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-4119
Mailing Address - Country:US
Mailing Address - Phone:770-505-7190
Mailing Address - Fax:770-793-7413
Practice Address - Street 1:504 W MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-4119
Practice Address - Country:US
Practice Address - Phone:770-505-7190
Practice Address - Fax:770-793-7413
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044656207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology