Provider Demographics
NPI:1346233053
Name:VILLANUEVA, EDWARD EUSEBIO (DPM)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:EUSEBIO
Last Name:VILLANUEVA
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 1:2501 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-1010
Mailing Address - Country:US
Mailing Address - Phone:610-623-3540
Mailing Address - Fax:610-623-2327
Practice Address - Street 1:2501 GARRETT RD
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-1010
Practice Address - Country:US
Practice Address - Phone:610-623-3540
Practice Address - Fax:610-623-2327
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-27
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003875L213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015260540002Medicaid
PAU56365Medicare UPIN
PA0015260540002Medicaid
PA776795Medicare PIN