Provider Demographics
NPI:1164875902
Name:GONZALEZ VILLALBA, JOSE ADOLFO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ADOLFO
Last Name:GONZALEZ VILLALBA
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 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:322 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379-2839
Practice Address - Country:US
Practice Address - Phone:864-429-8029
Practice Address - Fax:864-429-3515
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0091283208M00000X
CODR.0062854208M00000X
SC86507207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC865077Medicaid
SCSCL150H888OtherMEDICARE PIN