Provider Demographics
NPI:1275538092
Name:VILLALON, SOLOMON (MD)
Entity Type:Individual
Prefix:
First Name:SOLOMON
Middle Name:
Last Name:VILLALON
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 150
Mailing Address - Street 2:809 MAIN ST. STE 3
Mailing Address - City:WALSENBURG
Mailing Address - State:CO
Mailing Address - Zip Code:81089-0150
Mailing Address - Country:US
Mailing Address - Phone:719-738-2606
Mailing Address - Fax:719-738-1746
Practice Address - Street 1:809 MAIN ST
Practice Address - Street 2:SUITE #3
Practice Address - City:WALSENBURG
Practice Address - State:CO
Practice Address - Zip Code:81089-2149
Practice Address - Country:US
Practice Address - Phone:719-738-2606
Practice Address - Fax:719-738-1746
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20315207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01203157Medicaid
CO92401Medicare ID - Type Unspecified
COD23759Medicare UPIN
CO01203157Medicaid