Basic Information
| Provider Information | |||||||||
| NPI: | 1467728618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VICTORIA | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | FAITH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAJA | ||||||||
| OtherFirstName: | CHRISTINE | ||||||||
| OtherMiddleName: | FAITH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DR | ||||||||
| Address2: | PO BOX 0446 LOBBY J | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347476766 | ||||||||
| FaxNumber: | 7342223100 | ||||||||
| Practice Location | |||||||||
| Address1: | 49650 CHERRY HILL RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481874859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343987899 | ||||||||
| FaxNumber: | 7343987895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2012 | ||||||||
| LastUpdateDate: | 06/03/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301107191 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.