Provider Demographics
NPI:1679539886
Name:VALLEJO, VICTOR A (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:A
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 1:2300 PATTERSON ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1538
Mailing Address - Country:US
Mailing Address - Phone:615-342-6828
Mailing Address - Fax:615-342-6836
Practice Address - Street 1:2300 PATTERSON ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1538
Practice Address - Country:US
Practice Address - Phone:615-342-6828
Practice Address - Fax:615-342-6836
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38642207R00000X
SC28788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01016892OtherRAILROAD MEDICARE
TN4308730OtherBCBST
TN1514976Medicaid
SC287889Medicaid
KY7100189690Medicaid
TN6011152OtherBLUE CROSS-BLUE SHIELD
TN1514976Medicaid
TN4308730OtherBCBST
I11307Medicare UPIN
TNP01016892OtherRAILROAD MEDICARE