Provider Demographics
NPI:1891864047
Name:VALLE, JORGE A (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:A
Last Name:VALLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9530 BONITA BEACH RD SE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4769
Mailing Address - Country:US
Mailing Address - Phone:239-444-1903
Mailing Address - Fax:239-444-2391
Practice Address - Street 1:9530 BONITA BEACH RD SE
Practice Address - Street 2:SUITE 104
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4769
Practice Address - Country:US
Practice Address - Phone:239-444-1903
Practice Address - Fax:239-444-2391
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD12530Medicare UPIN