Provider Demographics
NPI:1689783912
Name:MANCHA, VICTOR M (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:M
Last Name:MANCHA
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 1:9501 PASEO DEL NORTE NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2998
Mailing Address - Country:US
Mailing Address - Phone:505-821-9630
Mailing Address - Fax:505-821-1705
Practice Address - Street 1:9501 PASEO DEL NORTE NE
Practice Address - Street 2:STE. B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122
Practice Address - Country:US
Practice Address - Phone:505-821-9630
Practice Address - Fax:505-821-1705
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM90-242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME1299Medicaid
E12623Medicare UPIN