MEDICARE: DR. JEFF T VICTOR D.O.

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	207RG0100X	Gastroenterology Physician	036102795	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	203529	OTHER	IL	MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104824887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFF T VICTOR D.O.

Provider Business Mailing Address
First Line	:	PO BOX 7630
Second Line	:
City	:	GURNEE
State	:	IL
Zip	:	60031-7002
Country	:	US
Telephone Number	:	630-208-7388
Fax Number	:	630-208-4818

Provider Business Practice Location Address
First Line	:	2455 DEAN ST STE A&B
Second Line	:
City	:	ST CHARLES
State	:	IL
Zip	:	60175-4830
Country	:	US
Telephone Number	:	630-208-7388
Fax Number	:	630-208-4818

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	05/07/2021

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