Provider Demographics
NPI:1093431264
Name:VALLEJO, DIEGO RUBEN
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:RUBEN
Last Name:VALLEJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1266
Mailing Address - Country:US
Mailing Address - Phone:575-993-2956
Mailing Address - Fax:
Practice Address - Street 1:118 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1266
Practice Address - Country:US
Practice Address - Phone:575-993-2956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist