Basic Information
| Provider Information | |||||||||
| NPI: | 1629295480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADRIGAL | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 WORTH ST STE C-1025 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148651020 | ||||||||
| FaxNumber: | 2148233270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 583408 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | AP112028 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 159902916 | 05 | TX | MEDICAID |