Provider Demographics
NPI:1699334094
Name:HUNDERTMARK, VICTORIA ROSE (MD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:ROSE
Last Name:HUNDERTMARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VICTORIA
Other - Middle Name:ROSE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:BYRD CLINIC
Mailing Address - Street 2:7973 DESTINY BLVD
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BYRD HEALTH/ADKINS CLINIC
Practice Address - Street 2:7973 DESTINY BLVD
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:270-412-1412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01380343940773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine