Provider Demographics
NPI:1427148931
Name:VICKERS, ANGELA J (MD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:J
Last Name:VICKERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:J
Other - Last Name:ROSAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:916-736-6798
Practice Address - Street 1:1625 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816
Practice Address - Country:US
Practice Address - Phone:916-262-9108
Practice Address - Fax:916-262-9109
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33100036174400000X
CAG65356174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G653560Medicaid
CA00G653560Medicaid
CAF11036Medicare UPIN