Provider Demographics
NPI:1336194596
Name:HERESNIAK, VICTOR A (DO)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:A
Last Name:HERESNIAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13973
Mailing Address - Street 2:HAN EMERGENCY PHYSICIANS
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101
Mailing Address - Country:US
Mailing Address - Phone:800-666-2455
Mailing Address - Fax:610-617-6280
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:CROZER CHESTER MEDICAL CENTER
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013
Practice Address - Country:US
Practice Address - Phone:215-447-2000
Practice Address - Fax:610-617-6280
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0013340207P00000X
PAOS 008170207P00000X
NJ25MB05928100207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1427270Medicaid
NJ5500702Medicaid
PA191333Medicare ID - Type Unspecified