Healthcare Provider Details

I. General information

NPI: 1134326556
Provider Name (Legal Business Name): VICTOR G LACOMBE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 MENDOCINO AVE
SANTA ROSA CA
95401-4330
US

IV. Provider business mailing address

1002 MENDOCINO AVE
SANTA ROSA CA
95401-4330
US

V. Phone/Fax

Practice location:
  • Phone: 707-577-8292
  • Fax: 707-575-3941
Mailing address:
  • Phone: 707-577-8292
  • Fax: 707-575-3941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberA065465
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: