Provider Demographics
NPI:1861855140
Name:FEDOROV, VIKTOR VASILYEVICH
Entity Type:Individual
Prefix:
First Name:VIKTOR
Middle Name:VASILYEVICH
Last Name:FEDOROV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:VIKTOR
Other - Middle Name:VASILYEVICH
Other - Last Name:STANKOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2131 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7407
Mailing Address - Country:US
Mailing Address - Phone:910-343-7000
Mailing Address - Fax:910-667-5650
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-343-7000
Practice Address - Fax:910-667-5650
Is Sole Proprietor?:No
Enumeration Date:2016-04-03
Last Update Date:2016-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC218430390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program