Basic Information
| Provider Information | |||||||||
| NPI: | 1053457457 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VALDOSTA ORTHOPEDIC ASSOCIATES PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VALDOSTA ORTHOPEDIC ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3527 N VALDOSTA ROAD | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316021068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292472290 | ||||||||
| FaxNumber: | 2292442626 | ||||||||
| Practice Location | |||||||||
| Address1: | 3527 N VALDOSTA ROAD | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316021068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292472290 | ||||||||
| FaxNumber: | 2292442626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AGUERO | ||||||||
| AuthorizedOfficialFirstName: | OSCAR | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2292472290 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000304554D | 05 | GA | MEDICAID | 000544662A | 05 | GA | MEDICAID | 000954445A | 05 | GA | MEDICAID | 000327973B | 05 | GA | MEDICAID | 000653353A | 05 | GA | MEDICAID | GRP1215 | 01 | GA | MEDICARE PTAN | OTHER |