Provider Demographics
NPI:1497753255
Name:VILLASENOR, ROBERTO M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:M
Last Name:VILLASENOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 MIDDLEFORD RD
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-3604
Mailing Address - Country:US
Mailing Address - Phone:302-629-7605
Mailing Address - Fax:302-629-2323
Practice Address - Street 1:916 MIDDLEFORD RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3604
Practice Address - Country:US
Practice Address - Phone:302-629-7605
Practice Address - Fax:302-629-2323
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-12-07
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
DEC10001573207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE103501Medicaid
DEB66499Medicare UPIN
DE131689Medicare PIN