Provider Demographics
NPI:1518581834
Name:VILLASENOR, ERIC EDWARD
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:EDWARD
Last Name:VILLASENOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 E TUDOR RD STE 9A
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1036
Mailing Address - Country:US
Mailing Address - Phone:907-332-0065
Mailing Address - Fax:907-290-3261
Practice Address - Street 1:1515 E TUDOR RD STE 9A
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-1036
Practice Address - Country:US
Practice Address - Phone:907-332-0065
Practice Address - Fax:907-290-3261
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKDSDSCERT171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK7502796OtherAKDL