Provider Demographics
NPI:1326027426
Name:VILLAGONZALO, VICTOR (DPM)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:
Last Name:VILLAGONZALO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 N TRIPHAMMER RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1576
Mailing Address - Country:US
Mailing Address - Phone:607-257-8877
Mailing Address - Fax:607-257-8879
Practice Address - Street 1:2255 N TRIPHAMMER RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1576
Practice Address - Country:US
Practice Address - Phone:607-257-8877
Practice Address - Fax:607-257-8879
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005881213E00000X
GA000992213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02862408Medicaid
NY6130290001Medicare NSC