Basic Information
| Provider Information | |||||||||
| NPI: | 1710970017 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ARCHIE | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 LAKE WRIGHT DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235021871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572135700 | ||||||||
| FaxNumber: | 7572135701 | ||||||||
| Practice Location | |||||||||
| Address1: | 2790 GODWIN BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234348151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575390670 | ||||||||
| FaxNumber: | 7575391062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 09/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 0101241369 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1710970017 | 05 | VA | MEDICAID | P00396160 | 01 | VA | RAILROAD MEDICARE | OTHER | 10018054 | 01 | VA | OPTIMA | OTHER |