Healthcare Provider Details

I. General information

NPI: 1417069774
Provider Name (Legal Business Name): RAYMOND R. VALDIVIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9550 W VAN BUREN ST SUITE 1
TOLLESON AZ
85353-2826
US

IV. Provider business mailing address

9550 W VAN BUREN ST SUITE 1
TOLLESON AZ
85353-2826
US

V. Phone/Fax

Practice location:
  • Phone: 623-936-7960
  • Fax: 623-936-7980
Mailing address:
  • Phone: 623-936-7960
  • Fax: 623-936-7980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22654
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: