Provider Demographics
NPI:1093742413
Name:VILLARREAL, JORGE RAMON (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:RAMON
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 22201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-2201
Mailing Address - Country:US
Mailing Address - Phone:317-614-9863
Mailing Address - Fax:844-876-0873
Practice Address - Street 1:2400 DUNDEE RD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-1166
Practice Address - Country:US
Practice Address - Phone:317-614-9863
Practice Address - Fax:844-876-0873
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0054730207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005537900Medicaid
FL372469700Medicaid
FL18400Medicare ID - Type Unspecified