Healthcare Provider Details

I. General information

NPI: 1568959930
Provider Name (Legal Business Name): CHARLES TAYLOR VALADIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 W MARTIN ST # MS 49-2
SAN ANTONIO TX
78207-0903
US

IV. Provider business mailing address

8904 FOREST BREEZE DR
CORDOVA TN
38018-7685
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-0572
  • Fax:
Mailing address:
  • Phone: 901-336-9187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10063267
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberT1868
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: