Provider Demographics
NPI:1144288275
Name:MALDONADO, VICTOR (MD)
Entity type:Individual
Prefix:PROF
First Name:VICTOR
Middle Name:
Last Name:MALDONADO
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 1:36175 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3274
Mailing Address - Country:US
Mailing Address - Phone:586-741-3772
Mailing Address - Fax:586-741-4604
Practice Address - Street 1:36175 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-3274
Practice Address - Country:US
Practice Address - Phone:586-741-3772
Practice Address - Fax:586-741-4604
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010431422085R0202X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q26008OtherBCBS PROVIDER NUMBER
MI4856349Medicaid
1006439OtherMCCLAREN HEALTH
0Q26008OtherBLUE CARE NETWORK
Q26008059OtherRR MEDICARE
0Q26008OtherBLUE CARE NETWORK