Provider Demographics
NPI:1568468395
Name:VINES, VICTOR L (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:L
Last Name:VINES
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 1:700 LONDONDERRY LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-7878
Mailing Address - Country:US
Mailing Address - Phone:940-387-3871
Mailing Address - Fax:940-243-8001
Practice Address - Street 1:700 LONDONDERRY LN
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-7878
Practice Address - Country:US
Practice Address - Phone:940-387-3871
Practice Address - Fax:940-243-8001
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8483207V00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115235704Medicaid
TX8BD727OtherBCBS
TX115235705Medicaid
TX8437B0OtherBCBS
TX115235705Medicaid
TX160052082Medicare PIN