Healthcare Provider Details

I. General information

NPI: 1902556236
Provider Name (Legal Business Name): CHARLES VALLEJO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MEADOWS RD
BOCA RATON FL
33486-2304
US

IV. Provider business mailing address

800 MEADOWS RD
BOCA RATON FL
33486-2304
US

V. Phone/Fax

Practice location:
  • Phone: 561-955-5365
  • Fax:
Mailing address:
  • Phone: 561-955-5365
  • Fax: 561-955-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS21166
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: