Healthcare Provider Details

I. General information

NPI: 1720141815
Provider Name (Legal Business Name): DR. VICTORIA O SOYANNWO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA O RAIWE MD

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 05/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E APACHE PARK PL
TUCSON AZ
85714-1775
US

IV. Provider business mailing address

6050 N CORONA RD
TUCSON AZ
85704-1096
US

V. Phone/Fax

Practice location:
  • Phone: 520-746-0260
  • Fax: 520-295-0834
Mailing address:
  • Phone: 520-682-4111
  • Fax: 520-682-4570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number42824
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: