Provider Demographics
NPI:1770696817
Name:VALLADARES, CARLOS (DO)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:VALLADARES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MEDICAL PARK
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-243-6530
Mailing Address - Fax:304-243-3840
Practice Address - Street 1:10 MEDICAL PARK
Practice Address - Street 2:SUITE 101
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-243-6530
Practice Address - Fax:304-243-3840
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3117208600000X
PAOS-009646-L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH47483Medicare UPIN
PA076383Medicare ID - Type Unspecified