Provider Demographics
NPI:1528261914
Name:CHAN, VICKIE C (MD)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:C
Last Name:CHAN
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-781-4111
Mailing Address - Fax:859-441-5214
Practice Address - Street 1:2626 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:KY
Practice Address - Zip Code:41076-1530
Practice Address - Country:US
Practice Address - Phone:859-781-4111
Practice Address - Fax:859-441-5214
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00847810OtherRAILROAD MEDICARE
KYP00408798OtherRAILROAD MEDICARE
OH2790967Medicaid
KY7100019390Medicaid
KYP00408798OtherRAILROAD MEDICARE
KY008580018Medicare PIN