Provider Demographics
NPI:1790777365
Name:VALLERA, RAPHAELLE D (MD)
Entity Type:Individual
Prefix:
First Name:RAPHAELLE
Middle Name:D
Last Name:VALLERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 GASTON AVE
Mailing Address - Street 2:SUITE 980
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2016
Mailing Address - Country:US
Mailing Address - Phone:469-800-8020
Mailing Address - Fax:469-800-8030
Practice Address - Street 1:3417 GASTON AVE
Practice Address - Street 2:SUITE 980
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2016
Practice Address - Country:US
Practice Address - Phone:469-800-8020
Practice Address - Fax:469-800-8030
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1711174400000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX900003262OtherRAILROAD MEDICARE
TX15857566OtherPACIFICARE
TX4242788002OtherCIGNA
TX031518601Medicaid
TX1420298OtherUNITED
TX5487391OtherAETNA
TX343132YKY6Medicare PIN
TX5487391OtherAETNA
TX4242788002OtherCIGNA