Provider Demographics
NPI:1265483580
Name:VILLAVICENCIO, JOSE R (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:VILLAVICENCIO
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 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4304
Practice Address - Street 1:601 ST RT 664
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138
Practice Address - Country:US
Practice Address - Phone:740-380-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069935V207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000326505OtherBCBS
P00139007OtherHOCKING MEDICARE RR
OH0386372Medicare ID - Type Unspecified
F37637Medicare UPIN
VI4014078Medicare ID - Type Unspecified