Provider Demographics
NPI:1174587141
Name:VASTINE, VICTORIA LEE (MD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LEE
Last Name:VASTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LEE
Other - Last Name:VASTINE-FOLGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 79777
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0777
Mailing Address - Country:US
Mailing Address - Phone:434-654-7794
Mailing Address - Fax:434-654-7752
Practice Address - Street 1:595 MARTHA JEFFERSON DR STE 280
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4669
Practice Address - Country:US
Practice Address - Phone:434-654-8920
Practice Address - Fax:434-654-8921
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010576572086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV5228AMedicare PIN
VAG79382Medicare UPIN