Basic Information
| Provider Information | |||||||||
| NPI: | 1801806443 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALDEZ | ||||||||
| FirstName: | BRICCIO | ||||||||
| MiddleName: | DIZON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6210 FLAT ROCK RD | ||||||||
| Address2: | APT. 6148 - B | ||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319079212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065685000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 SCHATULGA RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319073117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065685000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2084P0800X | 019353 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 019353 | 01 | GA | STATE OF GA LICENSE | OTHER |