Provider Demographics
NPI:1649218488
Name:VALENCIA, MIRNA (MD)
Entity Type:Individual
Prefix:
First Name:MIRNA
Middle Name:
Last Name:VALENCIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6525
Mailing Address - Country:US
Mailing Address - Phone:904-475-5800
Mailing Address - Fax:
Practice Address - Street 1:1536 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6525
Practice Address - Country:US
Practice Address - Phone:904-475-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93645207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30689OtherBCBS #
FL274023100Medicaid
FL274023100Medicaid
FL30689Medicare ID - Type UnspecifiedMCR #
FLI48679Medicare UPIN
FL30689AMedicare PIN