Provider Demographics
NPI:1962018960
Name:VICTORIA, JUAN SEBASTIAN
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:SEBASTIAN
Last Name:VICTORIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HELEN ST
Mailing Address - Street 2:
Mailing Address - City:ELLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12428-2010
Mailing Address - Country:US
Mailing Address - Phone:845-699-0632
Mailing Address - Fax:
Practice Address - Street 1:146 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02532-3902
Practice Address - Country:US
Practice Address - Phone:508-759-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046316225100000X
MA25775225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist