Provider Demographics
NPI:1043428204
Name:JOVELLANOS, VALENTIN PARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:VALENTIN
Middle Name:PARDO
Last Name:JOVELLANOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:BLAUVELT
Mailing Address - State:NY
Mailing Address - Zip Code:10913-1331
Mailing Address - Country:US
Mailing Address - Phone:845-613-7049
Mailing Address - Fax:212-567-0977
Practice Address - Street 1:20 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-1654
Practice Address - Country:US
Practice Address - Phone:212-567-1030
Practice Address - Fax:212-567-0977
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2219902080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02177484Medicaid