Basic Information
| Provider Information | |||||||||
| NPI: | 1851738702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VICTOR | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | ROOM 4102 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650239 | ||||||||
| FaxNumber: | 3522651107 | ||||||||
| Practice Location | |||||||||
| Address1: | 3998 RED LION RD STE 213 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191141440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156125699 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2013 | ||||||||
| LastUpdateDate: | 10/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | TRN19079 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084N0400X | MD462116 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.