Provider Demographics
NPI:1972050235
Name:VICTORINA'S DIABETES ENDOCRINOLOGY AND METABOLISM, INC
Entity type:Organization
Organization Name:VICTORINA'S DIABETES ENDOCRINOLOGY AND METABOLISM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILFRED
Authorized Official - Middle Name:MARCO
Authorized Official - Last Name:VICTORINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-496-1803
Mailing Address - Street 1:PO BOX 350812
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32135-0812
Mailing Address - Country:US
Mailing Address - Phone:386-225-4462
Mailing Address - Fax:386-225-4465
Practice Address - Street 1:4879 PALM COAST PKWY NW
Practice Address - Street 2:UNIT # 2
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3672
Practice Address - Country:US
Practice Address - Phone:386-225-4462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-04
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126126207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty