Healthcare Provider Details

I. General information

NPI: 1578599981
Provider Name (Legal Business Name): DAMION J VALLETTA DO PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7625 MESA COLLEGE DR STE 320A
SAN DIEGO CA
92111-5343
US

IV. Provider business mailing address

PO BOX 13533
LA JOLLA CA
92039-3533
US

V. Phone/Fax

Practice location:
  • Phone: 858-524-7000
  • Fax: 858-524-7005
Mailing address:
  • Phone: 858-524-7000
  • Fax: 858-524-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number20A8171
License Number StateCA

VIII. Authorized Official

Name: DAMION VALLETTA
Title or Position: PRESIDENT
Credential: D.O.
Phone: 858-524-7000