Provider Demographics
NPI:1194895607
Name:VICTOR, JACQUES ANDRE (MD)
Entity type:Individual
Prefix:
First Name:JACQUES
Middle Name:ANDRE
Last Name:VICTOR
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 1:5331 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-2707
Mailing Address - Country:US
Mailing Address - Phone:305-758-7894
Mailing Address - Fax:305-758-2050
Practice Address - Street 1:5331 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-2707
Practice Address - Country:US
Practice Address - Phone:305-758-7894
Practice Address - Fax:305-758-2050
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL036926208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
96221Medicare ID - Type Unspecified
D63780Medicare UPIN