Provider Demographics
NPI:1083704613
Name:VILLARREAL, MARCELO (MD)
Entity Type:Individual
Prefix:
First Name:MARCELO
Middle Name:
Last Name:VILLARREAL
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:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:LYTLE
Mailing Address - State:TX
Mailing Address - Zip Code:78052-0725
Mailing Address - Country:US
Mailing Address - Phone:210-357-0300
Mailing Address - Fax:210-357-0458
Practice Address - Street 1:470 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-4507
Practice Address - Country:US
Practice Address - Phone:210-357-0300
Practice Address - Fax:210-357-0458
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ96072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX047610301Medicaid
TX047610301Medicaid