Provider Demographics
NPI:1033220397
Name:VILLAJUAN, BERNARDO R (MD)
Entity Type:Individual
Prefix:
First Name:BERNARDO
Middle Name:R
Last Name:VILLAJUAN
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 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:319 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT EDWARD
Practice Address - State:NY
Practice Address - Zip Code:12828-1221
Practice Address - Country:US
Practice Address - Phone:518-761-0300
Practice Address - Fax:518-480-0119
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115492207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00366569Medicaid
NYB0850Medicare UPIN
NY00366569Medicaid