Provider Demographics
NPI:1376724468
Name:VALENTINE, GERALD WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:WAYNE
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 1:46 CENTAURUS RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-7912
Mailing Address - Country:US
Mailing Address - Phone:203-499-7474
Mailing Address - Fax:
Practice Address - Street 1:46 CENTAURUS RANCH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-7912
Practice Address - Country:US
Practice Address - Phone:203-499-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-17
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2012-00682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty