Provider Demographics
NPI:1770545873
Name:VICTORIA KIDNEY & DIALYSIS ASSOCIATES
Entity type:Organization
Organization Name:VICTORIA KIDNEY & DIALYSIS ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-576-0011
Mailing Address - Street 1:605 E SAN ANTONIO
Mailing Address - Street 2:SUITE 430E
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901
Mailing Address - Country:US
Mailing Address - Phone:361-576-0011
Mailing Address - Fax:361-576-4084
Practice Address - Street 1:605 E SAN ANTONIO
Practice Address - Street 2:SUITE 430E
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901
Practice Address - Country:US
Practice Address - Phone:361-576-0011
Practice Address - Fax:361-576-4084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080560802Medicaid
TX080560801Medicaid
TX00421KMedicare PIN
TX080560802Medicaid