Healthcare Provider Details

I. General information

NPI: 1013348689
Provider Name (Legal Business Name): VICTORY MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2372 VICTORY BLVD
STATEN ISLAND NY
10314-6607
US

IV. Provider business mailing address

2372 VICTORY BLVD
STATEN ISLAND NY
10314-6607
US

V. Phone/Fax

Practice location:
  • Phone: 718-761-3700
  • Fax: 718-698-3090
Mailing address:
  • Phone: 718-761-3700
  • Fax: 718-698-3090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number192446
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number192446
License Number StateNY

VIII. Authorized Official

Name: MICHAEL JUDE LACQUA
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 718-761-3700