Provider Demographics
NPI:1427218726
Name:VALENZUELA, PERCIVAL (IDC)
Entity Type:Individual
Prefix:
First Name:PERCIVAL
Middle Name:
Last Name:VALENZUELA
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 COVE RD
Mailing Address - Street 2:BLDG 3806
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23521-2911
Mailing Address - Country:US
Mailing Address - Phone:757-462-3780
Mailing Address - Fax:757-462-4825
Practice Address - Street 1:1865 COVE RD
Practice Address - Street 2:BLDG 3806
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23521-2911
Practice Address - Country:US
Practice Address - Phone:757-462-3780
Practice Address - Fax:757-462-4825
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZB1505257146N00000X
1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic