Provider Demographics
NPI:1780974147
Name:VIRGILIO C VICTORIANO MD PC
Entity type:Organization
Organization Name:VIRGILIO C VICTORIANO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGILIO
Authorized Official - Middle Name:C
Authorized Official - Last Name:VICTORIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-453-2206
Mailing Address - Street 1:105 EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1407
Mailing Address - Country:US
Mailing Address - Phone:518-453-2206
Mailing Address - Fax:518-453-2209
Practice Address - Street 1:105 EVERETT RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1407
Practice Address - Country:US
Practice Address - Phone:518-453-2206
Practice Address - Fax:518-453-2209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115869174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000535075Medicaid