Provider Demographics
NPI:1710091640
Name:VALDES, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:VALDES
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 1:514 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3631
Mailing Address - Country:US
Mailing Address - Phone:262-548-7666
Mailing Address - Fax:262-970-6696
Practice Address - Street 1:514 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3631
Practice Address - Country:US
Practice Address - Phone:262-548-7666
Practice Address - Fax:262-970-6696
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010772342084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2602900651OtherBCBS OF MI
MI4897207Medicaid
WI01175-0107Medicare PIN
MIG95367Medicare UPIN
MI4897207Medicaid