Provider Demographics
NPI:1306857677
Name:VALLE, LATICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:LATICIA
Middle Name:
Last Name:VALLE
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 1:1000 SOUTH AVE
Mailing Address - Street 2:BOX 108
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2733
Mailing Address - Country:US
Mailing Address - Phone:585-341-0209
Mailing Address - Fax:
Practice Address - Street 1:990 SOUTH AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-2763
Practice Address - Country:US
Practice Address - Phone:585-341-6775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233972207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
J400075581OtherMEDICARE PTAN
NY02657183Medicaid