Provider Demographics
NPI:1033112958
Name:VILLANUEVA, ROBERTO MANUEL (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:MANUEL
Last Name:VILLANUEVA
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 1:1240 JESSE JEWELL PKWY SE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3862
Mailing Address - Country:US
Mailing Address - Phone:770-536-9864
Mailing Address - Fax:
Practice Address - Street 1:1240 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE 500
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3862
Practice Address - Country:US
Practice Address - Phone:770-536-9864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052312207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H84894Medicare UPIN
11BDWSTMedicare ID - Type Unspecified
GA081144699AMedicaid