Provider Demographics
NPI:1528219813
Name:VILLALON-GOMEZ, JOSE MANUEL (MD, MPH)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:VILLALON-GOMEZ
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 N SHALLOWFORD RD
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6476
Mailing Address - Country:US
Mailing Address - Phone:404-778-6920
Mailing Address - Fax:404-778-6901
Practice Address - Street 1:4500 N SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-6476
Practice Address - Country:US
Practice Address - Phone:404-778-6920
Practice Address - Fax:404-778-6901
Is Sole Proprietor?:No
Enumeration Date:2008-10-05
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246442207Q00000X
FLME103333207Q00000X
GA066097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109624AMedicaid
GA202I081944Medicare PIN