Provider Demographics
NPI:1881781631
Name:VICTORY, JAMES D (DC)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:D
Last Name:VICTORY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 760
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553
Mailing Address - Country:US
Mailing Address - Phone:228-497-9907
Mailing Address - Fax:228-497-9917
Practice Address - Street 1:315 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553
Practice Address - Country:US
Practice Address - Phone:228-497-9907
Practice Address - Fax:228-497-9917
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS980111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS64-0931880OtherTAX ID #
MS00123096Medicaid
MS1866765OtherFRIST HEALTH PROVIDER #
MS645632OtherUNITED HEALTHCARE PROVIDE
MS7614197OtherAETNA PROVIDER #
MS08755862Medicaid
MS08755862Medicaid
MS00123096Medicaid