Healthcare Provider Details

I. General information

NPI: 1295716124
Provider Name (Legal Business Name): VICTORIA P DIMAYUGA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 09/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 IROQUOIS TRL
ORMOND BEACH FL
32174-4333
US

IV. Provider business mailing address

16 IROQUOIS TRL
ORMOND BEACH FL
32174-4333
US

V. Phone/Fax

Practice location:
  • Phone: 386-615-0366
  • Fax:
Mailing address:
  • Phone: 386-615-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME053185
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberME 053185
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: