Basic Information
| Provider Information | |||||||||
| NPI: | 1689803215 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEANNETTE DEL VALLE MD, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | N/A | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 568 | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473080568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652840493 | ||||||||
| FaxNumber: | 7652842434 | ||||||||
| Practice Location | |||||||||
| Address1: | 769 MEDICAL CENTER CT | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919116602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194213313 | ||||||||
| FaxNumber: | 6194213315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 08/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | DEL VALLE | ||||||||
| AuthorizedOfficialFirstName: | JEANNETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6194213313 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D., F.A.C.G.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A42660 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A426600 | 05 | CA | MEDICAID | 1952370074 | 01 | CA | TYPE I NPI | OTHER | WA42660G | 01 | CA | MEDICARE ID-TYPE UNSPECIFIED | OTHER |