Provider Demographics
NPI:1164532446
Name:VILLANUEVA, JUVENTINO
Entity Type:Individual
Prefix:DR
First Name:JUVENTINO
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2589 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1446
Mailing Address - Country:US
Mailing Address - Phone:626-798-8792
Mailing Address - Fax:626-798-9607
Practice Address - Street 1:6601 RUGBY AVE
Practice Address - Street 2:300
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4040
Practice Address - Country:US
Practice Address - Phone:323-582-1177
Practice Address - Fax:323-589-2635
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA46207208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A462070OtherMEDI-CAL