Basic Information
| Provider Information | |||||||||
| NPI: | 1154318699 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALENZUELA | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | VALENZUELA | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | COMSTOCK | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 205 S DOBSON RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852246183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809636668 | ||||||||
| FaxNumber: | 4809636669 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 E BELL RD | ||||||||
| Address2: | SUITE 5100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029237730 | ||||||||
| FaxNumber: | 6029307833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 04/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 33580 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | BV9208895 | 01 | AZ | DEA | OTHER |