Provider Demographics
NPI:1013348507
Name:AJIDUAH, VALERIE O (PA)
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:O
Last Name:AJIDUAH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 FAIR OAKS AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5801
Mailing Address - Country:US
Mailing Address - Phone:626-346-2455
Mailing Address - Fax:626-639-3005
Practice Address - Street 1:3946 NORWOOD AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-1092
Practice Address - Country:US
Practice Address - Phone:916-564-0521
Practice Address - Fax:877-860-2907
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51325363A00000X
CAPA51325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASAC POD- EFF 5/22/14Medicaid
CAP0146687 - DV5277OtherRR MEDICARE - 55TH ST, NORWOOD, MARYSVILLE, MACK RD & CITRUS HEIGHTS LOCATIONS
CACA123575-GB232AMedicare PIN
CACA140789 - CA140503Medicare PIN