Basic Information
| Provider Information | |||||||||
| NPI: | 1154490191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOTH ENTERPRISES II | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VICTORY MEDICAL & FAMILY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4303 VICTORY DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787048870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124623627 | ||||||||
| FaxNumber: | 5124623431 | ||||||||
| Practice Location | |||||||||
| Address1: | 4303 VICTORY DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787048870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124623627 | ||||||||
| FaxNumber: | 5124623431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 02/18/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLE | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5124623627 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G6659 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 085758301 | 05 | TX | MEDICAID |