Provider Demographics
NPI:1437319977
Name:CHAN-VILLANUEVA, IMELDA V (MD)
Entity Type:Individual
Prefix:DR
First Name:IMELDA
Middle Name:V
Last Name:CHAN-VILLANUEVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:IMELDA
Other - Middle Name:C
Other - Last Name:VILLANUEVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:305 WOODLAND SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-1921
Mailing Address - Country:US
Mailing Address - Phone:775-544-8753
Mailing Address - Fax:
Practice Address - Street 1:100 W CROSS ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TX
Practice Address - Zip Code:77864-2432
Practice Address - Country:US
Practice Address - Phone:936-348-3418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243329207Q00000X
TXN0685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine