Provider Demographics
NPI:1578602504
Name:VICTORY, FARZAN (MD)
Entity Type:Individual
Prefix:
First Name:FARZAN
Middle Name:
Last Name:VICTORY
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:PO BOX 4934
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87196-4934
Mailing Address - Country:US
Mailing Address - Phone:505-298-0301
Mailing Address - Fax:
Practice Address - Street 1:601 DR MARTIN LUTHER KING JR AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3619
Practice Address - Country:US
Practice Address - Phone:505-298-0301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2006-0380208D00000X
VA01012492642085R0202X
NMMD2012-05972085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMA102940OtherMEDICARE PTAN
NM70379807Medicaid