Provider Demographics
NPI:1750386033
Name:ANDREWS VALLANCE, MILDRED ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:ELIZABETH
Last Name:ANDREWS VALLANCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 N VENTU PARK RD STE D
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-2755
Mailing Address - Country:US
Mailing Address - Phone:805-499-5525
Mailing Address - Fax:805-499-5554
Practice Address - Street 1:558 N. VENTU PARK RD., STE D
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320
Practice Address - Country:US
Practice Address - Phone:805-499-5525
Practice Address - Fax:805-499-5554
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233059208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006736904Medicaid
VA006736904Medicaid