Provider Demographics
NPI:1780623678
Name:VALENZUELA, ERICKA MARIA (DO)
Entity type:Individual
Prefix:
First Name:ERICKA
Middle Name:MARIA
Last Name:VALENZUELA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:76 BONIFACE DR
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-4612
Mailing Address - Country:US
Mailing Address - Phone:845-545-6212
Mailing Address - Fax:845-345-6212
Practice Address - Street 1:76 BONIFACE DR STE 1
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-4611
Practice Address - Country:US
Practice Address - Phone:845-545-6212
Practice Address - Fax:845-345-6212
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245028207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400159510Medicare PIN