Provider Demographics
NPI:1093027732
Name:VALLADARES, JOSE GUSTAVO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:GUSTAVO
Last Name:VALLADARES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-1415
Mailing Address - Country:US
Mailing Address - Phone:786-281-1005
Mailing Address - Fax:305-541-4644
Practice Address - Street 1:2660 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-1415
Practice Address - Country:US
Practice Address - Phone:786-281-1005
Practice Address - Fax:305-541-4644
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-10
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME957732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
EP060BMedicare PIN