Provider Demographics
NPI:1548623515
Name:VALENCIA, MARIO JR (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:VALENCIA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 123977 DEPT 3977
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-3977
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:2829 4TH AVE STE 150
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7897
Practice Address - Country:US
Practice Address - Phone:337-480-7800
Practice Address - Fax:337-474-4552
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLTRN 202182084P0800X
FLME1306372084P0800X
LA3092862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2476572Medicaid
LAMD.309286OtherSTATE LICENSE