Healthcare Provider Details

I. General information

NPI: 1205579117
Provider Name (Legal Business Name): JUAN ANTONIO VALADEZ DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N STATE COLLEGE BLVD STE H
FULLERTON CA
92831-4236
US

IV. Provider business mailing address

100 N STATE COLLEGE BLVD STE H
FULLERTON CA
92831-4236
US

V. Phone/Fax

Practice location:
  • Phone: 714-824-6565
  • Fax: 714-930-7926
Mailing address:
  • Phone: 714-824-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A20965
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number20A20965
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: