Provider Demographics
NPI:1598754285
Name:VALLEJOS, JAVIER M (MD)
Entity Type:Individual
Prefix:MR
First Name:JAVIER
Middle Name:M
Last Name:VALLEJOS
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:P.O. BOX 1680
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25717-1680
Mailing Address - Country:US
Mailing Address - Phone:304-697-1396
Mailing Address - Fax:304-697-2086
Practice Address - Street 1:22 FLEMING DRIVE
Practice Address - Street 2:
Practice Address - City:HARTS
Practice Address - State:WV
Practice Address - Zip Code:25524
Practice Address - Country:US
Practice Address - Phone:304-855-4595
Practice Address - Fax:304-529-0780
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11634207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001721259OtherBC
KY64694268Medicaid
WV0094185000Medicaid
WV4030431Medicare PIN
WV001721259OtherBC
WVWV3031AMedicare PIN