Provider Demographics
NPI:1538107719
Name:VICTOR, CARL HAROLD (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:HAROLD
Last Name:VICTOR
Suffix:
Gender:M
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:P.O. BOX 784976
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-4976
Mailing Address - Country:US
Mailing Address - Phone:609-815-7510
Mailing Address - Fax:609-815-7814
Practice Address - Street 1:1230 PARKWAY AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628
Practice Address - Country:US
Practice Address - Phone:609-883-5454
Practice Address - Fax:609-883-2565
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03570800207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2276101Medicaid
NJ2276101Medicaid
B34515Medicare UPIN
NJ456852VH6Medicare PIN