Provider Demographics
NPI:1083660351
Name:VICTORINA, WILFRED M (MD)
Entity Type:Individual
Prefix:DR
First Name:WILFRED
Middle Name:M
Last Name:VICTORINA
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: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:386-225-4465
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36980207RE0101X
PAMD432714207RE0101X
FLME126126207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2517486Medicaid
KY64041114Medicaid
KYH46617Medicare UPIN
OH2517486Medicaid
PAH46617Medicare UPIN
KY0974303Medicare PIN