Healthcare Provider Details

I. General information

NPI: 1366430555
Provider Name (Legal Business Name): VICTOR M. CAMACHO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 3RD ST
FORT POLK LA
71459-5102
US

IV. Provider business mailing address

PO BOX 5661
ATHENS GA
30604-5661
US

V. Phone/Fax

Practice location:
  • Phone: 337-531-3701
  • Fax:
Mailing address:
  • Phone: 706-354-5770
  • Fax: 706-354-5769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number023720
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: