Healthcare Provider Details

I. General information

NPI: 1114506771
Provider Name (Legal Business Name): VICTOR GOULENKO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 10TH CT STE 101
VERO BEACH FL
32960-5013
US

IV. Provider business mailing address

3555 10TH CT STE 101
VERO BEACH FL
32960-5013
US

V. Phone/Fax

Practice location:
  • Phone: 772-794-3333
  • Fax: 772-569-6949
Mailing address:
  • Phone: 772-794-3333
  • Fax: 772-569-6949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1508863242
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number180007
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: