Provider Demographics
NPI:1477673762
Name:VILLANUEVA GONZALEZ, WANDA I (MD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:I
Last Name:VILLANUEVA GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-328-0108
Mailing Address - Fax:386-325-1086
Practice Address - Street 1:1305 N ORANGE AVE
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-2547
Practice Address - Country:US
Practice Address - Phone:904-284-5904
Practice Address - Fax:904-284-5905
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN706208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIH341ZOtherFLORIFA MEDICARE
FL015593700Medicaid
FL015593700Medicaid