Provider Demographics
NPI:1629295480
Name:MADRIGAL, VICTOR (APRN)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:MADRIGAL
Suffix:
Gender:M
Credentials:APRN
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 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:3535 WORTH ST STE C-1025
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2006
Practice Address - Country:US
Practice Address - Phone:214-865-1020
Practice Address - Fax:214-823-3270
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX583408363L00000X
TXAP112028363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159902916Medicaid
TX159902902Medicaid
TX8L24574Medicare PIN
TX8G4208Medicare ID - Type UnspecifiedPROVIDER