Healthcare Provider Details

I. General information

NPI: 1659593606
Provider Name (Legal Business Name): ANTHONY REX VICTORIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 NORTHSTAR WAY
MODESTO CA
95356-9262
US

IV. Provider business mailing address

4301 NORTHSTAR WAY
MODESTO CA
95356-9262
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-1200
  • Fax: 209-577-6517
Mailing address:
  • Phone: 209-577-1200
  • Fax: 209-577-6517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberA86106
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA86106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: