Healthcare Provider Details

I. General information

NPI: 1245890706
Provider Name (Legal Business Name): EVAN JONATHAN VALLE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15031 RINALDI ST
MISSION HILLS CA
91345-1207
US

IV. Provider business mailing address

35 E GLENARM ST
PASADENA CA
91105-3418
US

V. Phone/Fax

Practice location:
  • Phone: 818-365-8051
  • Fax:
Mailing address:
  • Phone: 626-768-4415
  • Fax: 626-403-0321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: EVAN JONATHAN VALLEY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 650-201-1026