Provider Demographics
NPI:1669469706
Name:VALLEJO, RICARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:
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 1:1015 S MERCER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7107
Mailing Address - Country:US
Mailing Address - Phone:309-662-4321
Mailing Address - Fax:309-661-4532
Practice Address - Street 1:1015 S MERCER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7107
Practice Address - Country:US
Practice Address - Phone:309-662-4321
Practice Address - Fax:309-661-4532
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107002208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107002Medicaid
ILH74643Medicare UPIN