Provider Demographics
NPI:1932108305
Name:MAWN, VICTORIA BRADFORD (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:BRADFORD
Last Name:MAWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 KIRKWOOD HWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5123
Mailing Address - Country:US
Mailing Address - Phone:302-623-7500
Mailing Address - Fax:302-623-7505
Practice Address - Street 1:4512 KIRKWOOD HIGHWAY
Practice Address - Street 2:SUITE 300
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808
Practice Address - Country:US
Practice Address - Phone:302-623-7500
Practice Address - Fax:302-623-7505
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10004757207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE698201Medicaid
DE698201Medicaid
865675I71Medicare ID - Type Unspecified