Provider Demographics
NPI:1780338194
Name:CALDERON, VICTOR J SR
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:J
Last Name:CALDERON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 N 5TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133-2809
Mailing Address - Country:US
Mailing Address - Phone:215-668-6985
Mailing Address - Fax:
Practice Address - Street 1:3044 N 5TH ST FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-2809
Practice Address - Country:US
Practice Address - Phone:267-455-0158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-05
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA59243601251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA59243601Medicaid