Provider Demographics
NPI:1215017769
Name:VALDES, MAURICIO (MD)
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:VALDES
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 1:75A LAKE RD 155
Mailing Address - Street 2:
Mailing Address - City:CONGERS
Mailing Address - State:NY
Mailing Address - Zip Code:10920-2323
Mailing Address - Country:US
Mailing Address - Phone:914-965-0621
Mailing Address - Fax:
Practice Address - Street 1:136 S BROADWAY
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-4008
Practice Address - Country:US
Practice Address - Phone:914-965-0621
Practice Address - Fax:914-965-2040
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216884207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02107385Medicaid
NY08Q721Medicare ID - Type Unspecified
H16564Medicare UPIN