Provider Demographics
NPI:1417943580
Name:PATRICK, CRISTINA VILLANUEVA (OD)
Entity Type:Individual
Prefix:DR
First Name:CRISTINA
Middle Name:VILLANUEVA
Last Name:PATRICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:CRISTINA
Other - Last Name:VILLANUEVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 DIECKS DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2444
Mailing Address - Country:US
Mailing Address - Phone:270-769-1397
Mailing Address - Fax:270-765-4899
Practice Address - Street 1:103 DIECKS DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2444
Practice Address - Country:US
Practice Address - Phone:270-769-1397
Practice Address - Fax:270-765-4899
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1493DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00077642OtherRR MEDICARE
KY77000222Medicaid
MV0376168OtherDEA
KYP00077642OtherRR MEDICARE
KY0751802Medicare PIN
U71812Medicare UPIN