Basic Information
| Provider Information | |||||||||
| NPI: | 1851741896 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MLECZKO | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | LUIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103928636 | ||||||||
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| Practice Location | |||||||||
| Address1: | 604 ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103928636 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2016 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | A152130 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1851741896 | 05 | CA | MEDICAID |