Provider Demographics
NPI:1790949667
Name:VALLE, LUIS G (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:G
Last Name:VALLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1100 W SAGINAW ST STE 5
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48915-2033
Mailing Address - Country:US
Mailing Address - Phone:517-887-5922
Mailing Address - Fax:517-887-5982
Practice Address - Street 1:1100 W SAGINAW ST STE 5
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-2033
Practice Address - Country:US
Practice Address - Phone:517-887-5922
Practice Address - Fax:517-887-5982
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064984173000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1518983907Medicaid