Basic Information
Provider Information | |||||||||
NPI: | 1811199888 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VALERIO | ||||||||
FirstName: | IAN | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VALERIO | ||||||||
OtherFirstName: | IAN | ||||||||
OtherMiddleName: | L. | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432021559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142938566 | ||||||||
FaxNumber: | 6142933381 | ||||||||
Practice Location | |||||||||
Address1: | 915 OLENTANGY RIVER RD STE 2140 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432123153 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142938566 | ||||||||
FaxNumber: | 6142933381 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2007 | ||||||||
LastUpdateDate: | 05/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | MT183681 | PA | N |   | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 208200000X | 35123915 | OH | Y |   | Allopathic & Osteopathic Physicians | Plastic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0114039 | 05 | OH |   | MEDICAID |