Provider Demographics
NPI:1568853760
Name:VILELLA-GONZALEZ, LUIS S (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:S
Last Name:VILELLA-GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:S
Other - Last Name:VILELLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1776 WOODSTEAD CT STE 208
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-1480
Mailing Address - Country:US
Mailing Address - Phone:877-749-7428
Mailing Address - Fax:512-628-3314
Practice Address - Street 1:4671 38TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7866
Practice Address - Country:US
Practice Address - Phone:877-749-7428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0853208100000X
ND9273208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1466646Medicaid
ND1466646Medicaid