Provider Demographics
NPI:1346224839
Name:VICCARI, NICOLE GEORGANN (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:GEORGANN
Last Name:VICCARI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10945 N PORT WASHINGTON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5078
Mailing Address - Country:US
Mailing Address - Phone:262-292-3151
Mailing Address - Fax:
Practice Address - Street 1:10945 N PORT WASHINGTON RD STE 201
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5078
Practice Address - Country:US
Practice Address - Phone:262-292-3151
Practice Address - Fax:414-434-0467
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI703212085R0202X
PAMD4459272085R0202X
NY2620132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology