Provider Demographics
NPI:1912219791
Name:VALLEBO, SALVADOR ALINDADA JR (IDC)
Entity type:Individual
Prefix:MR
First Name:SALVADOR
Middle Name:ALINDADA
Last Name:VALLEBO
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:MR
Other - First Name:SALVADOR
Other - Middle Name:ALINDADA
Other - Last Name:VALLEBO
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:IDC
Mailing Address - Street 1:7914 GAYLEN RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2613
Mailing Address - Country:US
Mailing Address - Phone:858-547-3865
Mailing Address - Fax:
Practice Address - Street 1:7914 GAYLEN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2613
Practice Address - Country:US
Practice Address - Phone:858-547-3865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1002X
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman