Provider Demographics
NPI:1770787004
Name:VALERIE C. ALTAVAS MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:VALERIE C. ALTAVAS MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ALTAVAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-470-7000
Mailing Address - Street 1:PO BOX 1175
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91951-1175
Mailing Address - Country:US
Mailing Address - Phone:619-470-7000
Mailing Address - Fax:619-470-7009
Practice Address - Street 1:655 EUCLID AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2957
Practice Address - Country:US
Practice Address - Phone:619-470-7000
Practice Address - Fax:619-470-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52243207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC52243Medicare ID - Type Unspecified
CAG26167Medicare UPIN