Provider Demographics
NPI:1205015435
Name:ALEJANDRO A VICTORIA MD PA
Entity Type:Organization
Organization Name:ALEJANDRO A VICTORIA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEJANDRO
Authorized Official - Middle Name:A
Authorized Official - Last Name:VICTORIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-242-0676
Mailing Address - Street 1:235 HATTERAS AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2756
Mailing Address - Country:US
Mailing Address - Phone:352-242-0676
Mailing Address - Fax:352-242-1335
Practice Address - Street 1:235 HATTERAS
Practice Address - Street 2:SUITE 100
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2756
Practice Address - Country:US
Practice Address - Phone:352-242-0676
Practice Address - Fax:352-242-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83909207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06554OtherBCBS
FL06554OtherBCBS