Provider Demographics
NPI:1235525403
Name:VILLARREAL, DIANA DEROSA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:DEROSA
Last Name:VILLARREAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11175 CAMPUS ST
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1700
Mailing Address - Country:US
Mailing Address - Phone:909-558-8142
Mailing Address - Fax:909-558-5981
Practice Address - Street 1:11175 CAMPUS ST
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1700
Practice Address - Country:US
Practice Address - Phone:909-558-8142
Practice Address - Fax:909-558-5981
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA161918208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000169885Medicaid