Provider Demographics
NPI:1376561159
Name:VALENTINE, EUGENE RAPHAEL (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:RAPHAEL
Last Name:VALENTINE
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 1:235 CARMEL DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1957
Mailing Address - Country:US
Mailing Address - Phone:850-862-3141
Mailing Address - Fax:850-862-7732
Practice Address - Street 1:235 CARMEL DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1957
Practice Address - Country:US
Practice Address - Phone:850-862-3141
Practice Address - Fax:850-862-7732
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127562084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46079OtherBLUE CROSS BLUE SHIELD
FL052428000Medicaid
FL46079ZMedicare ID - Type Unspecified
FL052428000Medicaid