Provider Demographics
NPI:1083666234
Name:VILLANUEVA, RANDY JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:JOSEPH
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6027 WALNUT GROVE
Mailing Address - Street 2:SUITE 317
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2145
Mailing Address - Country:US
Mailing Address - Phone:901-818-3921
Mailing Address - Fax:901-767-3056
Practice Address - Street 1:6027 WALNUT GROVE
Practice Address - Street 2:SUITE 317
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2145
Practice Address - Country:US
Practice Address - Phone:901-818-3921
Practice Address - Fax:901-767-3056
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN39777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3335228Medicaid
TNI43767Medicare UPIN
TN3335228Medicaid