Provider Demographics
NPI:1821302035
Name:EDGARDO C VALLEJO INC
Entity Type:Organization
Organization Name:EDGARDO C VALLEJO INC
Other - Org Name:EDGARDO VALLEJO MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:C
Authorized Official - Last Name:VALLEJO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-352-1173
Mailing Address - Street 1:240 WILLIAMSON ST
Mailing Address - Street 2:SUITE 502
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-3674
Mailing Address - Country:US
Mailing Address - Phone:908-352-1173
Mailing Address - Fax:908-352-0665
Practice Address - Street 1:240 WILLIAMSON ST
Practice Address - Street 2:SUITE 502
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-3674
Practice Address - Country:US
Practice Address - Phone:908-352-1173
Practice Address - Fax:908-352-0665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03310600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1709801Medicaid
C55510Medicare UPIN
453783Medicare PIN