Provider Demographics
NPI:1609988112
Name:DE MOYA, VICTOR (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:DE MOYA
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 1:403A HOLLYWOOD BLVD,, NW
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4531
Mailing Address - Country:US
Mailing Address - Phone:850-244-0101
Mailing Address - Fax:850-243-9795
Practice Address - Street 1:403A HOLLYWOOD BLVD,, NW
Practice Address - Street 2:SUITE 104
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4531
Practice Address - Country:US
Practice Address - Phone:850-244-0101
Practice Address - Fax:850-243-9795
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL538692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09760OtherBLUE CROSS/BLUE SHIELD FL
FLE59513Medicare UPIN
FL09760YMedicare ID - Type Unspecified