Healthcare Provider Details

I. General information

NPI: 1083660351
Provider Name (Legal Business Name): WILFRED M VICTORINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 WASHINGTON AVENUE EXT
ALBANY NY
12203-5316
US

IV. Provider business mailing address

220 WASHINGTON AVENUE EXT
ALBANY NY
12203-5316
US

V. Phone/Fax

Practice location:
  • Phone: 518-489-4704
  • Fax: 518-489-0512
Mailing address:
  • Phone: 518-489-4704
  • Fax: 518-489-0512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number36980
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD432714
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number324056
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME126126
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: