Provider Demographics
NPI:1295999589
Name:VALENTINE, NASA (MD)
Entity type:Individual
Prefix:DR
First Name:NASA
Middle Name:
Last Name:VALENTINE
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 1:3862 CLAREMONT ST
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6020 SEABLUFF DR
Practice Address - Street 2:
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-2252
Practice Address - Country:US
Practice Address - Phone:310-862-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121819207Q00000X
CAA102556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121819OtherILLINIOIS STATE LICENSE
CAA102256OtherCALIFORNIA STATE LICENSE
CAA102256OtherCALIFORNIA STATE LICENSE