Provider Demographics
NPI:1942680426
Name:TATE, VICTORIA VANESSA (MD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:VANESSA
Last Name:TATE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 MOHAWK DR APT 204
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-5758
Mailing Address - Country:US
Mailing Address - Phone:562-832-7676
Mailing Address - Fax:
Practice Address - Street 1:532 HAYWOOD RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2711
Practice Address - Country:US
Practice Address - Phone:864-501-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL38266208600000X
SC38266208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery