Provider Demographics
NPI:1023122421
Name:VICTORIA, EDGAR TATING (MD)
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:TATING
Last Name:VICTORIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 97
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35902
Mailing Address - Country:US
Mailing Address - Phone:256-492-0131
Mailing Address - Fax:
Practice Address - Street 1:1411 PIEDMONT CUTOFF
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903
Practice Address - Country:US
Practice Address - Phone:256-492-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00007957204C00000X
AL7957208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL143995 (COMPLEX)Medicaid
AL51046490OtherBLUE CROSS
AL51094372OtherBLUECROSS
AL630736845OtherIRS TAXPER IDENTIFICATION
AL143752 (WADLEY)Medicaid
AL143836 (CLEBURNE)Medicaid
AL143754 (ANNISTON)Medicaid
AL100906Medicaid
AL000046490Medicaid
AL009923940Medicaid
AL143752 (WADLEY)Medicaid
AL51046490OtherBLUE CROSS
AL000046490Medicare ID - Type Unspecified
AL143995 (COMPLEX)Medicaid