Provider Demographics
NPI:1912981713
Name:TARASENKO, VALERY D (MD)
Entity type:Individual
Prefix:
First Name:VALERY
Middle Name:D
Last Name:TARASENKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BUTCHER RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-5616
Mailing Address - Country:US
Mailing Address - Phone:707-359-2255
Mailing Address - Fax:707-359-2259
Practice Address - Street 1:200 BUTCHER RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-5616
Practice Address - Country:US
Practice Address - Phone:707-359-2255
Practice Address - Fax:707-359-2259
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72444208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A724440Medicaid
H18775Medicare UPIN
CA00A724440Medicare PIN