Provider Demographics
NPI:1215193214
Name:IP, VICKI (MD)
Entity type:Individual
Prefix:DR
First Name:VICKI
Middle Name:
Last Name:IP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1816
Mailing Address - Country:US
Mailing Address - Phone:716-875-2904
Mailing Address - Fax:716-875-6717
Practice Address - Street 1:155 LAWN AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1816
Practice Address - Country:US
Practice Address - Phone:716-875-2904
Practice Address - Fax:716-875-6717
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003895-1208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1894155Medicaid