Provider Demographics
NPI:1790117984
Name:RICHARD G VALENZUELA MD PA
Entity Type:Organization
Organization Name:RICHARD G VALENZUELA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIERTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:VALENZUELA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-755-4007
Mailing Address - Street 1:348 NE METHODIST TER
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-3408
Mailing Address - Country:US
Mailing Address - Phone:386-755-4007
Mailing Address - Fax:
Practice Address - Street 1:348 NE METHODIST TER
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3408
Practice Address - Country:US
Practice Address - Phone:386-755-4007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116272174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty