Healthcare Provider Details

I. General information

NPI: 1730331141
Provider Name (Legal Business Name): VICTORY MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 VICTORY BLVD 2ND FLOOR
STATEN ISLAND NY
10301-2905
US

IV. Provider business mailing address

25 VICTORY BLVD 2ND FLOOR
STATEN ISLAND NY
10301-2905
US

V. Phone/Fax

Practice location:
  • Phone: 718-815-7246
  • Fax: 516-706-1085
Mailing address:
  • Phone: 718-815-7246
  • Fax: 516-706-1085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number148054
License Number StateNY

VIII. Authorized Official

Name: DR. DEPIKA BAJAJ
Title or Position: DIRECTOR
Credential: MD
Phone: 917-815-2299