Provider Demographics
NPI:1376183012
Name:VALLEJO, GREGORY (RDO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:VALLEJO
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3714 LONE TREE WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6018
Mailing Address - Country:US
Mailing Address - Phone:925-757-6677
Mailing Address - Fax:
Practice Address - Street 1:3714 LONE TREE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6018
Practice Address - Country:US
Practice Address - Phone:925-757-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDO2084156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician