Provider Demographics
NPI:1871118828
Name:EGEDUS, VICTORIA LYDIA (DO)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:LYDIA
Last Name:EGEDUS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LYDIA
Other - Last Name:EGEDUS HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:914 GRAND CT
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-5118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-432-9277
Practice Address - Fax:517-432-9414
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51510141592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5151014159Medicaid
MI5315216333Medicaid