Provider Demographics
NPI:1932175528
Name:VALLEJO, MANUEL C JR (MD,DMD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:C
Last Name:VALLEJO
Suffix:JR
Gender:M
Credentials:MD,DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-0710
Mailing Address - Country:US
Mailing Address - Phone:304-598-3100
Mailing Address - Fax:
Practice Address - Street 1:1322 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-0710
Practice Address - Country:US
Practice Address - Phone:304-598-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025489L174400000X
PAMD058203L207L00000X
WV25529207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001600607Medicaid
PA852940FEVMedicare ID - Type Unspecified
PA852940FEVMedicare PIN
PAG24394Medicare UPIN