Basic Information
| Provider Information | |||||||||
| NPI: | 1710243852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PASTRANA | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | MANUEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 W 68TH ST, SUITE 202, MEDICAL EDUCATION DEPT | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053642107 | ||||||||
| FaxNumber: | 3058469711 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 W 68TH ST, SUITE 202, MEDICAL EDUCATION DEPT | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053642107 | ||||||||
| FaxNumber: | 3058469711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2012 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/16/2020 | ||||||||
| NPIReactivationDate: | 05/06/2020 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208D00000X | ME158714 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.