Provider Demographics
NPI:1649220898
Name:VICTORIA, ALTAGRACIA ADALGIZA (MD)
Entity Type:Individual
Prefix:DR
First Name:ALTAGRACIA
Middle Name:ADALGIZA
Last Name:VICTORIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 NW 151ST ST STE 203
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2437
Mailing Address - Country:US
Mailing Address - Phone:305-822-4447
Mailing Address - Fax:305-822-4484
Practice Address - Street 1:5801 NW 151ST ST STE 203
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2437
Practice Address - Country:US
Practice Address - Phone:305-822-4447
Practice Address - Fax:305-822-4484
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-0070097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250584300Medicaid
FLME 0070097OtherLICENSE
FLG 38269Medicare UPIN
FL32191AMedicare ID - Type Unspecified