Basic Information
| Provider Information | |||||||||
| NPI: | 1477767754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALLEJOS | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1680 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257171680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046971396 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Practice Location | |||||||||
| Address1: | 1630 13TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046972014 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 12/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 24052 | WV | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 3810017819 | 05 | WV | MEDICAID | 000000665311 | 01 | WV | ANTHEM | OTHER | 3074284 | 05 | OH | MEDICAID | 000000306218 | 01 | WV | UNISON | OTHER | 7100124710 | 05 | KY | MEDICAID |