1942250188 NPI number — DR. GREGG A VALENZUELA M.D.

Table of content: DR. GREGG A VALENZUELA M.D. (NPI 1942250188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942250188 NPI number — DR. GREGG A VALENZUELA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VALENZUELA
Provider First Name:
GREGG
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942250188
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26666
Provider Second Line Business Mailing Address:
PHS PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-6666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-923-6770
Provider Business Mailing Address Fax Number:
505-923-5354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7702 E PARHAM RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23294-4371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-288-7901
Provider Business Practice Location Address Fax Number:
804-273-9167
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  0101036504 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5857449 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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