Provider Demographics
NPI:1255373841
Name:VICKERY, DONNA R (MD)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:R
Last Name:VICKERY
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 1:19 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-2530
Mailing Address - Country:US
Mailing Address - Phone:330-758-4515
Mailing Address - Fax:330-758-5121
Practice Address - Street 1:19 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-2530
Practice Address - Country:US
Practice Address - Phone:330-758-4515
Practice Address - Fax:330-758-5121
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05262400103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E53448Medicare UPIN