Healthcare Provider Details

I. General information

NPI: 1942760418
Provider Name (Legal Business Name): JOHAN JOSEPH VALLE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 05/30/2020
Certification Date: 05/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

2805 TALLOWOOD CT
PLANO TX
75074-3133
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 214-697-7338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125.074838
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: