Provider Demographics
NPI:1558693010
Name:VALDEZ, GERALD L (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:L
Last Name:VALDEZ
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W COAL AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6306
Mailing Address - Country:US
Mailing Address - Phone:505-863-4101
Mailing Address - Fax:505-863-4101
Practice Address - Street 1:210 W COAL AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6306
Practice Address - Country:US
Practice Address - Phone:505-863-4101
Practice Address - Fax:505-863-4101
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM56421842Medicaid