Provider Demographics
NPI:1841345873
Name:VALLEJO, RUBEN (MD)
Entity type:Individual
Prefix:DR
First Name:RUBEN
Middle Name:
Last Name:VALLEJO
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:PO BOX 19708
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33318-0708
Mailing Address - Country:US
Mailing Address - Phone:954-581-4111
Mailing Address - Fax:954-692-1963
Practice Address - Street 1:1777 S ANDREWS AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2517
Practice Address - Country:US
Practice Address - Phone:954-581-4111
Practice Address - Fax:954-692-1963
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME322902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710266754OtherGROUP NPI
FL038592100Medicaid
FL93726YMedicare PIN