Provider Demographics
NPI:1518550441
Name:VALLEJO, JORGE MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:MANUEL
Last Name:VALLEJO
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 1:2270 SW 131ST TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-5112
Mailing Address - Country:US
Mailing Address - Phone:305-720-9800
Mailing Address - Fax:
Practice Address - Street 1:2270 SW 131ST TER
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33325-5112
Practice Address - Country:US
Practice Address - Phone:305-720-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJDCATEMP-0359612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty