Provider Demographics
NPI:1518050467
Name:VALLEJO, EDGARDO C (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:C
Last Name:VALLEJO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:240 WILLIAMSON ST
Mailing Address - Street 2:SUITE 502
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202
Mailing Address - Country:US
Mailing Address - Phone:908-352-1173
Mailing Address - Fax:908-352-0665
Practice Address - Street 1:240 WILLIAMSON ST
Practice Address - Street 2:SUITE 502
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202
Practice Address - Country:US
Practice Address - Phone:908-352-1173
Practice Address - Fax:908-352-0665
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA03310600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1709801Medicaid
C55510Medicare UPIN
453783Medicare PIN