Provider Demographics
NPI:1104255454
Name:LACERVA, VICTOR (MD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:
Last Name:LACERVA
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 1:52 ZAMBRA WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-0154
Mailing Address - Country:US
Mailing Address - Phone:505-983-4233
Mailing Address - Fax:
Practice Address - Street 1:52 ZAMBRA WAY
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-0154
Practice Address - Country:US
Practice Address - Phone:505-983-4233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8056208000000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics