=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487926663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IGNACIO VALDES MD A PROFESSIONAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2012
-----------------------------------------------------
Last Update Date | 09/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 W EULALIA ST SUITE 211
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91204-2851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-502-4567
-----------------------------------------------------
Fax | 818-502-4569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 W EULALIA ST SUITE 211
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91204-2851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-502-4567
-----------------------------------------------------
Fax | 818-502-4569
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IGNACIO VALDES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-502-4567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | G62465
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------