Provider Demographics
NPI:1407006083
Name:ANDERSON, VICTORIA H (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:H
Last Name:ANDERSON
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 1:250 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2244
Mailing Address - Country:US
Mailing Address - Phone:706-389-6789
Mailing Address - Fax:706-227-7249
Practice Address - Street 1:250 NORTH AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-2244
Practice Address - Country:US
Practice Address - Phone:706-389-6789
Practice Address - Fax:706-227-7249
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK74312084P0800X
WY8136A2084P0800X
GA363332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003161850BMedicaid