Provider Demographics
NPI:1013348689
Name:VICTORY MEDICAL PLLC
Entity Type:Organization
Organization Name:VICTORY MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JUDE
Authorized Official - Last Name:LACQUA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-761-3700
Mailing Address - Street 1:2372 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6607
Mailing Address - Country:US
Mailing Address - Phone:718-761-3700
Mailing Address - Fax:718-698-3090
Practice Address - Street 1:2372 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6607
Practice Address - Country:US
Practice Address - Phone:718-761-3700
Practice Address - Fax:718-698-3090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192446208200000X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1992753883OtherNPI
NY28L2382Medicare PIN