Basic Information
| Provider Information | |||||||||
| NPI: | 1043413412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALDIVIA VALDIVIA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | MARTIN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10744 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337578744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275320002 | ||||||||
| FaxNumber: | 7272664928 | ||||||||
| Practice Location | |||||||||
| Address1: | 2727 W. MARTIN LUTHER KING JR. BLVD | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138794328 | ||||||||
| FaxNumber: | 8134438152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 10/22/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | PG 76521 | AZ | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 4301093755 | MI | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | ME122350 | FL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.