Provider Demographics
NPI:1902805575
Name:VICKARYOUS, BRIAN KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:VICKARYOUS
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:773 STIRLING CENTER PL
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4856
Mailing Address - Country:US
Mailing Address - Phone:407-977-4130
Mailing Address - Fax:407-977-4139
Practice Address - Street 1:773 STIRLING CENTER PL
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4856
Practice Address - Country:US
Practice Address - Phone:407-977-4130
Practice Address - Fax:407-977-4139
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME9748207X00000X
GA55351207XX0005X
FLME87792207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME97482OtherSTATE OF FLORIDA