Provider Demographics
NPI:1457453383
Name:PETIVAN, VICTORIA ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:ANNE
Last Name:PETIVAN
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 1:100 SULLIVAN WAY
Mailing Address - Street 2:
Mailing Address - City:WEST TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08628
Mailing Address - Country:US
Mailing Address - Phone:609-633-1502
Mailing Address - Fax:609-777-0327
Practice Address - Street 1:100 SULLIVAN WAY
Practice Address - Street 2:
Practice Address - City:WEST TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08628
Practice Address - Country:US
Practice Address - Phone:609-633-1502
Practice Address - Fax:609-777-0327
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA065167002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7216203Medicaid
NJF72540Medicare UPIN
NJ7216203Medicaid