Provider Demographics
NPI:1972524189
Name:ROBERTS, VICTOR RAGU (MD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:RAGU
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RAGHAVENDER
Other - Middle Name:RAO
Other - Last Name:VADDEPALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1403 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1000
Mailing Address - Country:US
Mailing Address - Phone:407-365-6722
Mailing Address - Fax:407-540-9764
Practice Address - Street 1:1403 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 207
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1000
Practice Address - Country:US
Practice Address - Phone:407-365-6722
Practice Address - Fax:407-540-9764
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 88739207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6973Medicare ID - Type Unspecified
FLU1869XMedicare PIN
U1869BMedicare PIN
FLU 1869 BMedicare UPIN
FLI 01333Medicare UPIN
FLU1869YMedicare PIN