Healthcare Provider Details

I. General information

NPI: 1376724468
Provider Name (Legal Business Name): GERALD WAYNE VALENTINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2007
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 CENTAURUS RANCH RD
SANTA FE NM
87507-7912
US

IV. Provider business mailing address

46 CENTAURUS RANCH RD
SANTA FE NM
87507-7912
US

V. Phone/Fax

Practice location:
  • Phone: 203-499-7474
  • Fax:
Mailing address:
  • Phone: 203-499-7474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2012-0068
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: