Provider Demographics
NPI:1275673758
Name:VICTOR INTERNAL MEDICINE & PEDIATRICS,P.C.
Entity Type:Organization
Organization Name:VICTOR INTERNAL MEDICINE & PEDIATRICS,P.C.
Other - Org Name:VICTOR HEALTH ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DWAIN
Authorized Official - Last Name:PENIRD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-924-2158
Mailing Address - Street 1:6532 ANTHONY DR STE A
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-1422
Mailing Address - Country:US
Mailing Address - Phone:585-924-2100
Mailing Address - Fax:585-398-1217
Practice Address - Street 1:6532 ANTHONY DR STE A
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-1422
Practice Address - Country:US
Practice Address - Phone:585-924-2100
Practice Address - Fax:585-398-1217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197675207R00000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty