Provider Demographics
NPI:1457309171
Name:MICKUNAS, VICTOR H (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:H
Last Name:MICKUNAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:VICTOR
Other - Middle Name:H
Other - Last Name:MICKUNAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1909 GRANBY ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-2349
Mailing Address - Country:US
Mailing Address - Phone:757-640-0022
Mailing Address - Fax:757-627-8064
Practice Address - Street 1:1909 GRANBY ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-2349
Practice Address - Country:US
Practice Address - Phone:757-640-0022
Practice Address - Fax:757-627-8064
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044606174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA13017OtherOPTIMA
VA006717331Medicaid
VA331437OtherANTHEM
VA331437OtherANTHEM