Healthcare Provider Details

I. General information

NPI: 1104255454
Provider Name (Legal Business Name): VICTOR LACERVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 ZAMBRA WAY
SANTA FE NM
87506-0154
US

IV. Provider business mailing address

52 ZAMBRA WAY
SANTA FE NM
87506-0154
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-4233
  • Fax:
Mailing address:
  • Phone: 505-983-4233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8056
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number8056
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: