Healthcare Provider Details

I. General information

NPI: 1477767754
Provider Name (Legal Business Name): ANDREA M VALLEJOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 13TH AVENUE
HUNTINGTON WV
25701
US

IV. Provider business mailing address

P.O. BOX 1680
HUNTINGTON WV
25717-1680
US

V. Phone/Fax

Practice location:
  • Phone: 304-697-2014
  • Fax:
Mailing address:
  • Phone: 304-697-1396
  • Fax: 304-697-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number24052
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: