Provider Demographics
NPI:1710970017
Name:ARCHIE, VICTOR C (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:C
Last Name:ARCHIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5900 LAKE WRIGHT DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-1871
Mailing Address - Country:US
Mailing Address - Phone:757-213-5700
Mailing Address - Fax:757-213-5701
Practice Address - Street 1:2790 GODWIN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8151
Practice Address - Country:US
Practice Address - Phone:757-539-0670
Practice Address - Fax:757-539-1062
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA01012413692085R0001X
FLME90888208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1710970017Medicaid
VAP00396160OtherRAILROAD MEDICARE
VA10018054OtherOPTIMA
VA1710970017Medicaid
VA013480V63Medicare PIN
VA013479V25Medicare PIN