Provider Demographics
NPI:1447463500
Name:VICTORIA, EDWARD S (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:S
Last Name:VICTORIA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2701 N TENAYA WAY STE 190
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1405
Mailing Address - Country:US
Mailing Address - Phone:702-463-3008
Mailing Address - Fax:702-304-2147
Practice Address - Street 1:2701 N TENAYA WAY STE 190
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1405
Practice Address - Country:US
Practice Address - Phone:702-463-3008
Practice Address - Fax:702-463-3051
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12452208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1447463500Medicaid
NV1447463500Medicaid