Provider Demographics
NPI:1417111857
Name:VALLEJO, DORIS (MD)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:
Last Name:VALLEJO
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:PO BOX 746087
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6087
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:1555 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-2910
Practice Address - Country:US
Practice Address - Phone:718-765-6367
Practice Address - Fax:347-523-8127
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189917207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F53053Medicare UPIN