Provider Demographics
NPI:1982693123
Name:DE LOACH, VICTOR E (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:E
Last Name:DE LOACH
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 1:782 PLYMOUTH ST UNIT 12
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:MA
Mailing Address - Zip Code:02343-1952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5045 FRUITVILLE RD UNIT 123B
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-2269
Practice Address - Country:US
Practice Address - Phone:772-203-4613
Practice Address - Fax:727-290-4383
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.19935207Q00000X
FL78151207V00000X
FLME78151208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022825500Medicaid
AL131855Medicaid
FL5474634OtherAETNA
FL58949OtherFLORIDA BLUE
AL132989Medicaid
FL266278OtherAVMED