1508817719 NPI number — RAYMOND VALDES M.D.

Table of content: RAYMOND VALDES M.D. (NPI 1508817719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508817719 NPI number — RAYMOND VALDES M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VALDES
Provider First Name:
RAYMOND
Provider Middle Name:
Provider Name Prefix Text:
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:
1508817719
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 SHOPPINGWAY BLVD STE A
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
WEST MEMPHIS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72301-1734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-733-1280
Provider Business Mailing Address Fax Number:
877-441-0008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 SHOPPINGWAY BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
WEST MEMPHIS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72301-1734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-733-1280
Provider Business Practice Location Address Fax Number:
870-733-9443
Provider Enumeration Date:
05/12/2006

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: 207R00000X , with the licence number:  MD0000034563 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 0E2536 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 140122001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1782327 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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