Mario RL Valenzuela, MD
Individual provider Active NPI Psychiatry Physician · Portage, WI
NPI 1255436705 · NPPES record last updated Apr 15, 2014
Key facts
- NPI
- 1255436705
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Psychiatry Physician 2084P0800X
- License
- 41231020 (WI)
- Practice address
- 2901 Hunters TRL
Portage, WI 53901-3403 - Phone
- (608) 742-5518
- Fax
- (608) 742-4087
- NPI assigned
- Sep 13, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 4
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20040428000761 | WI | Practitioner - Psychiatry | 1557358892 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 41231020 | WI | MD | Psychiatry Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Sauk County | Current |
Accepting new patients | |
| County of Sauk | Current |
Accepting new patients | |
| Sauk County | Current | Accepting new patients | |
| Affiliated Counseling Center, Inc | Psychiatry | Past |
Accepting new patients |
Locations
505 Broadway St
Baraboo, WI 53913
Phone (608) 355-4200
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | 41231020 | WI | Yes |
Addresses
Primary practice location
2901 Hunters TRL
Portage, WI 53901-3403
Mailing address
2901 Hunters TRL
PO Box 301
Portage, WI 53901-3403
Phone (608) 742-5518
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 32603500 | Medicaid | WI |
Other providers in Portage, WI
- Timothy J Rosin DDS SC
- Theresa Tonn
- Melissa Trago
- Transitions Behavioral Health, LLC
- University of Wisconsin Medical Foundation Inc
- Matthew J Vanderkooi
- Theodore Vandermeuse
- Saikham Vang
- Angela Vantreeck
- Tiffany Verhasselt
All providers in Portage, WI · Psychiatry Physician in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 15, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.