Provider Demographics
NPI:1275573487
Name:VALLETTA, MARY ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELLEN
Last Name:VALLETTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:FL
Mailing Address - Zip Code:32693-3239
Mailing Address - Country:US
Mailing Address - Phone:352-463-2374
Mailing Address - Fax:352-463-4507
Practice Address - Street 1:2010 N YOUNG BLVD
Practice Address - Street 2:
Practice Address - City:CHIEFLAND
Practice Address - State:FL
Practice Address - Zip Code:32626-1951
Practice Address - Country:US
Practice Address - Phone:352-463-2374
Practice Address - Fax:352-463-4507
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90984208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270589300Medicaid
I15499Medicare UPIN