Provider Demographics
NPI:1295734275
Name:VAN FOSSEN, VICTORIA (MD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 ARCH ST STE 280
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44304-1499
Mailing Address - Country:US
Mailing Address - Phone:330-564-2438
Mailing Address - Fax:330-564-2442
Practice Address - Street 1:95 ARCH ST STE 280
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1499
Practice Address - Country:US
Practice Address - Phone:330-564-2438
Practice Address - Fax:330-564-2442
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35064327208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2039109Medicaid
OHP00211104OtherRAILROAD MEDICARE
OH000000334071OtherANTHEM BC/BS
OH0819472Medicare ID - Type Unspecified
OHG49952Medicare UPIN