Provider Demographics
NPI:1366496366
Name:VILLAVICENCIO, THEODORE R (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
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 1:10791 KITTY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433
Mailing Address - Country:US
Mailing Address - Phone:303-838-4686
Mailing Address - Fax:303-816-4905
Practice Address - Street 1:10791 KITTY DR
Practice Address - Street 2:SUITE A
Practice Address - City:CONIFER
Practice Address - State:CO
Practice Address - Zip Code:80433
Practice Address - Country:US
Practice Address - Phone:303-838-4686
Practice Address - Fax:303-816-4905
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F07712Medicare UPIN
99338Medicare ID - Type Unspecified