Provider Demographics
NPI:1780615872
Name:ANTLE-VLACH, VICTORIA J (MD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:J
Last Name:ANTLE-VLACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:J
Other - Last Name:VLACH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1000 W 4TH ST
Mailing Address - Street 2:SUITE 13
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-3730
Mailing Address - Country:US
Mailing Address - Phone:605-668-8795
Mailing Address - Fax:605-668-9705
Practice Address - Street 1:1000 W 4TH ST
Practice Address - Street 2:SUITE 13
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-3730
Practice Address - Country:US
Practice Address - Phone:605-668-8795
Practice Address - Fax:605-668-9705
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD8743207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100363610BMedicaid
MO202996088Medicaid
SD8743OtherSTATE LICENSE
SD8743OtherSTATE LICENSE