Provider Demographics
NPI:1790941086
Name:VALERA, LAURIE JOY BLANCO (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:JOY BLANCO
Last Name:VALERA
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-0344
Mailing Address - Country:US
Mailing Address - Phone:765-828-1003
Mailing Address - Fax:765-828-1030
Practice Address - Street 1:114 N. DIVISION
Practice Address - Street 2:
Practice Address - City:CAYUGA
Practice Address - State:IN
Practice Address - Zip Code:47928-8230
Practice Address - Country:US
Practice Address - Phone:765-492-9042
Practice Address - Fax:765-492-9048
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013528A207Q00000X
IN01065814A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200954800Medicaid
IN254390HMedicare PIN
IN200954800Medicaid
IN941090BB2Medicare PIN