Provider Demographics
NPI:1003396177
Name:VILLANUEVA, DWIGHT MARSHALL TAN (RRT)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:MARSHALL TAN
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:DWIGHT
Other - Middle Name:TAN
Other - Last Name:VILLANUEVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RRT
Mailing Address - Street 1:18518 BETTY WAY
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-6320
Mailing Address - Country:US
Mailing Address - Phone:714-684-4257
Mailing Address - Fax:
Practice Address - Street 1:3440 E LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2020
Practice Address - Country:US
Practice Address - Phone:714-644-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25583227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered