Basic Information
| Provider Information | |||||||||
| NPI: | 1851390454 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALENZUELA | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6633 N MESA ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799124422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155004093 | ||||||||
| FaxNumber: | 9155004167 | ||||||||
| Practice Location | |||||||||
| Address1: | 6633 N MESA ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799124422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157262175 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 20030658 | NM | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | M1391 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 94708266 | 05 | NM | MEDICAID | P00674960 | 01 | TX | RAILROAD | OTHER | 8AA317 | 01 | TX | BCBS | OTHER | 172867701 | 05 | TX | MEDICAID |