Healthcare Provider Details

I. General information

NPI: 1275794885
Provider Name (Legal Business Name): ROLANDO GABRIEL VALENZUELA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HSC LEVEL 4 RM 080 DEPARTMENT OF EMERGENCY MEDICINE
STONY BROOK NY
11794
US

IV. Provider business mailing address

436 SW 15TH RD
MIAMI FL
33129-1011
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2478
  • Fax: 323-226-6465
Mailing address:
  • Phone: 917-439-1662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA121092
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2883733
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number53074
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME160487
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: