Provider Demographics
NPI:1447418397
Name:VILLARREAL, EDWIN ENRIQUE (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:ENRIQUE
Last Name:VILLARREAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDWIN
Other - Middle Name:VILLARREAL
Other - Last Name:MAZZILLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:541 HISTORIC HWY 441-N
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4528
Practice Address - Country:US
Practice Address - Phone:770-219-7078
Practice Address - Fax:770-219-7365
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN63221208M00000X
GA066663207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine