Provider Demographics
NPI:1477722296
Name:VILLANUEVA, CANDELARIO (DISPENSUNG OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:CANDELARIO
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:DISPENSUNG OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 LATOUCHE ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4209
Mailing Address - Country:US
Mailing Address - Phone:907-562-2845
Mailing Address - Fax:907-562-2956
Practice Address - Street 1:3500 LATOUCHE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4209
Practice Address - Country:US
Practice Address - Phone:907-562-2845
Practice Address - Fax:907-562-2956
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA159156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOP1159Medicaid