Provider Demographics
NPI:1801077094
Name:PLASENCIA, VICTOR RAFAEL (MD)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:RAFAEL
Last Name:PLASENCIA
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 1:5939 W DIVERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1155
Mailing Address - Country:US
Mailing Address - Phone:773-637-1600
Mailing Address - Fax:773-637-1520
Practice Address - Street 1:5939 W DIVERSEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1155
Practice Address - Country:US
Practice Address - Phone:773-637-1600
Practice Address - Fax:773-637-2733
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036112680208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics