Provider Demographics
NPI:1669518205
Name:OWUSU-YAW, VICTOR (MD)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:OWUSU-YAW
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 1:129 BROAD ST # B
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-2301
Mailing Address - Country:US
Mailing Address - Phone:434-791-2600
Mailing Address - Fax:434-792-5347
Practice Address - Street 1:129 BROAD ST # B
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2301
Practice Address - Country:US
Practice Address - Phone:434-791-2600
Practice Address - Fax:434-792-5347
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2022-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010517742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080464OtherANTHEM BLUE CROSS BLUE SH
NC890607AMedicaid
VA46215Medicaid
VA006018947Medicaid
70219OtherSOUTHERN HEALTH
VA006018947Medicaid
70219OtherSOUTHERN HEALTH
VA080464OtherANTHEM BLUE CROSS BLUE SH