Provider Demographics
NPI:1003927203
Name:VALLEJO, PAUL S (DPM)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:S
Last Name:VALLEJO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16606 PENNARD LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1236
Mailing Address - Country:US
Mailing Address - Phone:909-822-2075
Mailing Address - Fax:866-389-5723
Practice Address - Street 1:410 W CENTRAL AVE
Practice Address - Street 2:204
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3014
Practice Address - Country:US
Practice Address - Phone:714-990-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4299213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91587Medicare UPIN