1104519461 NPI number — DR. MCKENON VICTOR ABREU DPM

Table of content: DR. MCKENON VICTOR ABREU DPM (NPI 1104519461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104519461 NPI number — DR. MCKENON VICTOR ABREU DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABREU
Provider First Name:
MCKENON
Provider Middle Name:
VICTOR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104519461
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13802 JAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALLEY CENTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92082-5819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-807-0307
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1660 S COLUMBIAN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98108-1532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-762-1010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)