Basic Information
| Provider Information | |||||||||
| NPI: | 1346302056 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALDEZ | ||||||||
| FirstName: | MILA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BROOKDALE PLZ STE 666 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112123139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182407143 | ||||||||
| FaxNumber: | 7182405808 | ||||||||
| Practice Location | |||||||||
| Address1: | 1873 EASTERN PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112333214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182408600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2006 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 140304 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00571040 | 05 | NY | MEDICAID |