Basic Information
| Provider Information | |||||||||
| NPI: | 1245272384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALDES-VEGA | ||||||||
| FirstName: | EDEL | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412 W VINE ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074830672 | ||||||||
| FaxNumber: | 4073485882 | ||||||||
| Practice Location | |||||||||
| Address1: | 1412 W VINE ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074830672 | ||||||||
| FaxNumber: | 4073485882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
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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 | 12845 | PR | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | ACN437 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 004787100 | 05 | FL | MEDICAID |