Provider Demographics
NPI:1912223280
Name:VICTORY MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:VICTORY MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KLOBOCISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-698-0710
Mailing Address - Street 1:220 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2919
Mailing Address - Country:US
Mailing Address - Phone:718-447-1080
Mailing Address - Fax:718-447-1559
Practice Address - Street 1:220 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2919
Practice Address - Country:US
Practice Address - Phone:718-447-1080
Practice Address - Fax:718-447-1559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY255828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty