Basic Information
Provider Information | |||||||||
NPI: | 1528071198 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VALBUENA | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 310 EISENHOWER DR | ||||||||
Address2: | BLDG # 7 | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314062632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123556503 | ||||||||
FaxNumber: | 9123559837 | ||||||||
Practice Location | |||||||||
Address1: | 310 EISENHOWER DR | ||||||||
Address2: | BLDG # 7 | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314062632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123556503 | ||||||||
FaxNumber: | 9123559837 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2006 | ||||||||
LastUpdateDate: | 01/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 973 | GA | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 897396002A | 05 | GA |   | MEDICAID |