Provider Demographics
NPI:1255436705
Name:VALENZUELA, MARIO RL (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:RL
Last Name:VALENZUELA
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 1:2901 HUNTERS TRL
Mailing Address - Street 2:PO BOX 301
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-3403
Mailing Address - Country:US
Mailing Address - Phone:608-742-5518
Mailing Address - Fax:608-742-4087
Practice Address - Street 1:2901 HUNTERS TRL
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-3403
Practice Address - Country:US
Practice Address - Phone:608-742-5518
Practice Address - Fax:608-742-4087
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI412310202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32603500Medicaid
WIG99304Medicare UPIN
WI0022Medicare ID - Type Unspecified