Basic Information
| Provider Information | |||||||||
| NPI: | 1861166290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALLE MORADEL | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | ALEJANDRO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7605 RESERVE CIR APT 4 | ||||||||
| Address2: | |||||||||
| City: | WINDSOR MILL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212441617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2407948110 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 900 S CATON AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212295299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6672345724 | ||||||||
| FaxNumber: | 6672343525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2021 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | G479136 | 01 | PASSPORT | OTHER |