Provider Demographics
NPI:1093806093
Name:OYAS, VIC S (MD)
Entity Type:Individual
Prefix:DR
First Name:VIC
Middle Name:S
Last Name:OYAS
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 1:1980 MESQUITE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-7713
Mailing Address - Country:US
Mailing Address - Phone:928-680-1919
Mailing Address - Fax:928-680-0488
Practice Address - Street 1:1980 MESQUITE AVE STE 101
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-7713
Practice Address - Country:US
Practice Address - Phone:928-680-1919
Practice Address - Fax:928-680-0488
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ 21390208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0345820OtherBC/BS PROVIDER NUMBER
AZ138819Medicaid