MEDICARE: ANGELIQUE MERCEDES DELA VICTORIA OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1179	NV

General Provider Information

NPI Number	:	1073291522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELIQUE MERCEDES DELA VICTORIA OD

Provider Business Mailing Address
First Line	:	5094 MASOTTA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89141-3887
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2870 S MARYLAND PKWY STE 300
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-1552
Country	:	US
Telephone Number	:	27-242-0207
Fax Number	:	702-724-2800

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2023
Last Update Date	:	09/20/2024

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