Provider Demographics
NPI:1245409382
Name:VICTOR DERMATOLOGY & REJUVENATION, PC
Entity Type:Organization
Organization Name:VICTOR DERMATOLOGY & REJUVENATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:VICTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-249-3050
Mailing Address - Street 1:30 E 76TH ST
Mailing Address - Street 2:6 FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-2700
Mailing Address - Country:US
Mailing Address - Phone:212-249-3050
Mailing Address - Fax:212-249-1482
Practice Address - Street 1:30 E 76TH ST
Practice Address - Street 2:6 FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2700
Practice Address - Country:US
Practice Address - Phone:212-249-3050
Practice Address - Fax:212-249-1482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138656174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVI0WLR1510Medicare UPIN