Provider Demographics
NPI:1861855140
Name:FEDOROV, VIKTOR VASILYEVICH (DO)
Entity type:Individual
Prefix:
First Name:VIKTOR
Middle Name:VASILYEVICH
Last Name:FEDOROV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:VIKTOR
Other - Middle Name:VASILYEVICH
Other - Last Name:STANKOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:255 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6333
Mailing Address - Country:US
Mailing Address - Phone:910-353-7848
Mailing Address - Fax:
Practice Address - Street 1:255 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6333
Practice Address - Country:US
Practice Address - Phone:910-353-7848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-03
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC218430390200000X
NC2024-01637208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program