Provider Demographics
NPI:1710165469
Name:SERGIO H. VALLEJO M. D. , P. A.
Entity Type:Organization
Organization Name:SERGIO H. VALLEJO M. D. , P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-688-0512
Mailing Address - Street 1:1543 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3246
Mailing Address - Country:US
Mailing Address - Phone:863-688-0512
Mailing Address - Fax:863-686-6895
Practice Address - Street 1:1543 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3246
Practice Address - Country:US
Practice Address - Phone:863-688-0512
Practice Address - Fax:863-686-6895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME23925173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258723800Medicaid
FLK1372OtherMEDICARE PART B
FL258723800Medicaid