Provider Demographics
NPI:1366402612
Name:VICKAR, GARRY MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:GARRY
Middle Name:MARTIN
Last Name:VICKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11125 DUNN ROAD
Mailing Address - Street 2:SUITE 213
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6132
Mailing Address - Country:US
Mailing Address - Phone:314-837-4900
Mailing Address - Fax:314-837-5646
Practice Address - Street 1:11125 DUNN ROAD
Practice Address - Street 2:SUITE 213
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6132
Practice Address - Country:US
Practice Address - Phone:314-837-4900
Practice Address - Fax:314-837-5646
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR50512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200794402Medicaid
MO001011487Medicare PIN
MO200794402Medicaid