Provider Demographics
NPI:1740262229
Name:DEL VALLE, JUAN JORGE JR (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:JORGE
Last Name:DEL VALLE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JORGE
Other - Middle Name:
Other - Last Name:DEL VALLE
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2116 E ORANGEBURG AVE
Mailing Address - Street 2:# C
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3370
Mailing Address - Country:US
Mailing Address - Phone:209-589-1500
Mailing Address - Fax:209-521-0813
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4405
Practice Address - Country:US
Practice Address - Phone:209-578-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA122664OtherBOARD CERTIFICATION #
CA00A819700Medicaid
CA00A819700OtherBLUE SHIELD OF CA PIN
CA00A819700OtherBLUE SHIELD OF CA PIN
CA122664OtherBOARD CERTIFICATION #
CAH85170Medicare UPIN