Basic Information
Provider Information | |||||||||
NPI: | 1265403158 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VALLESTEROS | ||||||||
FirstName: | ALFREDO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1906 BELLEVIEW AVE SE | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240141838 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5409817000 | ||||||||
FaxNumber: | 5408530931 | ||||||||
Practice Location | |||||||||
Address1: | 3208 HERSHBERGER RD NW | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240171842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5403665248 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2006 | ||||||||
LastUpdateDate: | 08/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 0101221482 | VA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 0101221482 | VA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RA0401X | 0101221482 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
ID Information
ID | Type | State | Issuer | Description | 010403626 | 05 | VA |   | MEDICAID | P00403472 | 01 | VA | MEDICARE RAILROAD | OTHER | 1265403158 | 05 | VA |   | MEDICAID | P00277240 | 01 | VA | MEDICARE RAILROAD | OTHER |