Provider Demographics
NPI:1366430555
Name:CAMACHO, VICTOR M (MD)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:M
Last Name:CAMACHO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5661
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-5661
Mailing Address - Country:US
Mailing Address - Phone:706-354-5770
Mailing Address - Fax:706-354-5769
Practice Address - Street 1:1585 3RD ST
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-3701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023720207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000267803VMedicaid
GA000267803VMedicaid
D44995Medicare UPIN
GA930125646Medicare ID - Type UnspecifiedRAILROAD MEDICARE