Provider Demographics
NPI:1205516937
Name:VALDIVIESO, EDBAJAR RAMON (RVT, RDCS, BS)
Entity type:Individual
Prefix:
First Name:EDBAJAR
Middle Name:RAMON
Last Name:VALDIVIESO
Suffix:
Gender:M
Credentials:RVT, RDCS, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 NEWBURY RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-6435
Mailing Address - Country:US
Mailing Address - Phone:661-309-5037
Mailing Address - Fax:
Practice Address - Street 1:1000 NEWBURY RD STE 270
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-6445
Practice Address - Country:US
Practice Address - Phone:661-309-5037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-18
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1029172471S1302X, 2085R0202X, 2085R0204X, 2085U0001X, 2471V0105X, 2471V0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography
No2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional Technology