Individual
DR. KENNETH DYLAN VICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 815-1800
Mailing address
301 SAINT IVES DR, MADISON, MS 39110-7183
(601) 853-8769
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
18940
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01220266
—
MS
01
—
P01198277
RAILROAD MEDICARE PTAN
MS
Enumeration date
07/17/2006
Last updated
09/10/2013
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