=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053303255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE LUIS VALLADARES MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2005
-----------------------------------------------------
Last Update Date | 08/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 E SAN ANTONIO ST STE 310E
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901-6053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-485-9600
-----------------------------------------------------
Fax | 361-485-9610
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 E SAN ANTONIO ST STE 310E
-----------------------------------------------------
City | VICTORIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77901-6053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 361-485-9600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | 036.096247
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | L5595
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------