Healthcare Provider Details

I. General information

NPI: 1558693010
Provider Name (Legal Business Name): GERALD L VALDEZ OPTICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 02/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W COAL AVE
GALLUP NM
87301-6306
US

IV. Provider business mailing address

210 W COAL AVE
GALLUP NM
87301-6306
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-4101
  • Fax: 505-863-4101
Mailing address:
  • Phone: 505-863-4101
  • Fax: 505-863-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: