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Individual
CRAIG A VICKSTROM
Active
Individual
CRAIG A VICKSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
4301086855
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
010Z760020 CV086855
BLUE CROSS - ER SERVICES
—
01
—
080Z710040 CV086855
BLUE CROSS - OFFICE
MI
05
—
4795539
—
MI
05
—
4797112
—
MI
Enumeration date
08/30/2006
Last updated
09/13/2013
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