Provider Demographics
NPI:1043413412
Name:VALDIVIA VALDIVIA, JUAN MARTIN (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:MARTIN
Last Name:VALDIVIA VALDIVIA
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:PO BOX 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4928
Practice Address - Street 1:2727 W. MARTIN LUTHER KING JR. BLVD
Practice Address - Street 2:SUITE 460
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6383
Practice Address - Country:US
Practice Address - Phone:813-879-4328
Practice Address - Fax:813-443-8152
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPG 76521207T00000X
MI4301093755207T00000X
FLME122350207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIB535YMedicare PIN
FLIB535ZMedicare PIN