Basic Information
Provider Information | |||||||||
NPI: | 1366866477 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VICTORIA PROFESSIONAL MEDICAL CONSULTANTS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3689 | ||||||||
Address2: |   | ||||||||
City: | SUGAR LAND | ||||||||
State: | TX | ||||||||
PostalCode: | 774873310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009623303 | ||||||||
FaxNumber: | 4056821586 | ||||||||
Practice Location | |||||||||
Address1: | 815 N VIRGINIA ST | ||||||||
Address2: |   | ||||||||
City: | PORT LAVACA | ||||||||
State: | TX | ||||||||
PostalCode: | 779793025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3615526713 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/10/2014 | ||||||||
LastUpdateDate: | 12/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ZIMMERMAN | ||||||||
AuthorizedOfficialFirstName: | BRETT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 2052401159 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.