Provider Demographics
NPI:1275566309
Name:PACHECO-FOWLER, VICTOR ALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:ALBERTO
Last Name:PACHECO-FOWLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VICTOR
Other - Middle Name:ALBERTO
Other - Last Name:PACHECO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER
Mailing Address - Street 2:UNIT 33100
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-3100
Mailing Address - Country:US
Mailing Address - Phone:314-590-6322
Mailing Address - Fax:
Practice Address - Street 1:LANDSTUHL REGIONAL MEDICAL CENTER
Practice Address - Street 2:UNIT 33100
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:314-590-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2022-09-28
Deactivation Date:2006-07-19
Deactivation Code:
Reactivation Date:2006-10-24
Provider Licenses
StateLicense IDTaxonomies
GUM1977207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01704585Medicaid
NY01704585Medicaid
NY01704585Medicaid