1720141815 NPI number — DR. VICTORIA O SOYANNWO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720141815 NPI number — DR. VICTORIA O SOYANNWO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOYANNWO
Provider First Name:
VICTORIA
Provider Middle Name:
O
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAIWE
Provider Other First Name:
VICTORIA
Provider Other Middle Name:
O
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720141815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6050 N CORONA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85704-1096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-682-4111
Provider Business Mailing Address Fax Number:
520-682-4570

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 E APACHE PARK PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85714-1775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-746-0260
Provider Business Practice Location Address Fax Number:
520-295-0834
Provider Enumeration Date:
12/19/2006

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: 2084P0800X , with the licence number:  42824 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03728354 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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