Provider Demographics
NPI:1578763686
Name:TEJADA, VICTOR MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:MANUEL
Last Name:TEJADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:130 CARBONTON RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4009
Practice Address - Country:US
Practice Address - Phone:919-774-6521
Practice Address - Fax:919-776-6179
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC289072084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1578763686OtherHUMANA
NC1578763686Medicaid
NC1578763686OtherUBH
NC1578763686OtherGATEWAY HEALTH
NC82334OtherBCBS
NC170407-000OtherMAGELLAN