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General NPI Number Information
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NPI Number | 1972050235
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Entity Type | Organization
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Legal Business Name | VICTORINA'S DIABETES ENDOCRINOLOGY AND METABOLISM, INC
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Dates
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Enumeration Date | 09/04/2016
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Last Update Date | 04/06/2017
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Provider Practice Location Address
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Address Line | 4879 PALM COAST PKWY NW UNIT # 2
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City | PALM COAST
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State | FL
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Zip | 32137-3672
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Country | US
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Telephone | 386-225-4462
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 350812
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City | PALM COAST
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State | FL
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Zip | 32135-0812
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Country | US
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Telephone | 386-225-4462
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Fax | 386-225-4465
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WILFRED MARCO VICTORINA
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Credential | M.D.
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Telephone | 859-496-1803
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | ME126126
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License Number State | FL
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