Provider Demographics
NPI:1265441760
Name:RILEY, VICTORIA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYNN
Last Name:RILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 WATERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5266
Mailing Address - Country:US
Mailing Address - Phone:407-975-0412
Mailing Address - Fax:407-975-0413
Practice Address - Street 1:1000 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5266
Practice Address - Country:US
Practice Address - Phone:407-975-0412
Practice Address - Fax:407-975-0413
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89026208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268858100Medicaid
FL376882Medicare ID - Type Unspecified
FL268858100Medicaid