Provider Demographics
NPI:1740595339
Name:CARLOS F VALLEJO MD PA
Entity Type:Organization
Organization Name:CARLOS F VALLEJO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:F
Authorized Official - Last Name:VALLEJO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-696-8802
Mailing Address - Street 1:5803 NW 151ST ST
Mailing Address - Street 2:STE 101
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2473
Mailing Address - Country:US
Mailing Address - Phone:305-696-8802
Mailing Address - Fax:305-696-8156
Practice Address - Street 1:5803 NW 151ST ST
Practice Address - Street 2:STE 101
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2473
Practice Address - Country:US
Practice Address - Phone:305-696-8802
Practice Address - Fax:305-696-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069920207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty