Provider Demographics
NPI:1043327273
Name:VALENZUELA, SEVERIANO (MD)
Entity type:Individual
Prefix:DR
First Name:SEVERIANO
Middle Name:
Last Name:VALENZUELA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 TYLER LN
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-9279
Mailing Address - Country:US
Mailing Address - Phone:909-982-2985
Mailing Address - Fax:
Practice Address - Street 1:1109 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2212
Practice Address - Country:US
Practice Address - Phone:818-244-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2025-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG2061702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA40981Medicare UPIN