Provider Demographics
NPI:1386027506
Name:VILLAVICENCIO SUMIRE, ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:VILLAVICENCIO SUMIRE
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 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5044
Mailing Address - Country:US
Mailing Address - Phone:573-471-1600
Mailing Address - Fax:
Practice Address - Street 1:135 PLAZA DR STE 102
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5148
Practice Address - Country:US
Practice Address - Phone:573-471-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR753142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology