MEDICARE: SERGIO H. VALLEJO M. D. , P. A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173000000X	Legal Medicine	ME23925	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	K1372	OTHER	FL	MEDICARE PART B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710165469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SERGIO H. VALLEJO M. D. , P. A.

Provider Business Mailing Address
First Line	:	1543 LAKELAND HILLS BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-3246
Country	:	US
Telephone Number	:	863-688-0512
Fax Number	:	863-686-6895

Provider Business Practice Location Address
First Line	:	1543 LAKELAND HILLS BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-3246
Country	:	US
Telephone Number	:	863-688-0512
Fax Number	:	863-686-6895

Authorized Official
Title or Position	:	SECRETARY
Name	:	MS. DIANE JORDAN
Credential	:
Telephone Number	:	863-688-0512

Provider Enumeration Date	:	02/05/2008
Last Update Date	:	08/16/2010

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