Provider Demographics
NPI:1598797110
Name:VALLETTA, GLENN ALLAN
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:ALLAN
Last Name:VALLETTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5066 SE FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5066 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6627
Practice Address - Country:US
Practice Address - Phone:772-286-0021
Practice Address - Fax:772-286-0021
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1710152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078258100Medicaid
FL078258100Medicaid
FL19184Medicare ID - Type Unspecified