Basic Information
Provider Information | |||||||||
NPI: | 1558306928 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VALDES-MURUA | ||||||||
FirstName: | HONORIO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3333 EVERGREEN DR NE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495259493 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6163644200 | ||||||||
FaxNumber: | 6163647347 | ||||||||
Practice Location | |||||||||
Address1: | 3333 EVERGREEN DR NE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495259493 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6163644200 | ||||||||
FaxNumber: | 6163647347 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2006 | ||||||||
LastUpdateDate: | 07/03/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 0420011014 | VT | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | 4301093674 | MI | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 1012055 | 05 | VT |   | MEDICAID | 8000976 | 01 | VT | LADIES FIRST | OTHER | 30210515 | 05 | NH |   | MEDICAID | 00068924 | 01 | VT | BC/VT | OTHER | M71590-114 | 01 | MI | MEDICARE | OTHER | P00263337 | 01 | VT | RR MEDICARE | OTHER |