Provider Demographics
NPI:1720141815
Name:SOYANNWO, VICTORIA O
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:O
Last Name:SOYANNWO
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:VICTORIA
Other - Middle Name:O
Other - Last Name:RAIWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6050 N CORONA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-1096
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-682-4570
Practice Address - Street 1:1601 E APACHE PARK PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714-1775
Practice Address - Country:US
Practice Address - Phone:520-746-0260
Practice Address - Fax:520-295-0834
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2018-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ428242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03728354Medicaid
MS03728354Medicaid
H99026Medicare UPIN