1790941086 NPI number — LAURIE JOY BLANCO VALERA M.D.

Table of content: LAURIE JOY BLANCO VALERA M.D. (NPI 1790941086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790941086 NPI number — LAURIE JOY BLANCO VALERA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VALERA
Provider First Name:
LAURIE
Provider Middle Name:
JOY BLANCO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1790941086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 344
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47842-0344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-828-1003
Provider Business Mailing Address Fax Number:
765-828-1030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 N. DIVISION
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAYUGA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47928-8230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-492-9042
Provider Business Practice Location Address Fax Number:
765-492-9048
Provider Enumeration Date:
08/06/2008

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: 207Q00000X , with the licence number:  11013528A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: 01065814A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200954800 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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