Provider Demographics
NPI:1740791193
Name:PATTERSON, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-2363
Mailing Address - Country:US
Mailing Address - Phone:313-412-5171
Mailing Address - Fax:
Practice Address - Street 1:7521 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-2229
Practice Address - Country:US
Practice Address - Phone:313-436-4661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2701169133335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier