Provider Demographics
NPI:1588660930
Name:VILLADONIGA, GRACIELA BEATRIZ (MD)
Entity Type:Individual
Prefix:
First Name:GRACIELA
Middle Name:BEATRIZ
Last Name:VILLADONIGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 E 29TH ST STE 123
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2691
Mailing Address - Country:US
Mailing Address - Phone:979-776-9400
Mailing Address - Fax:979-774-8903
Practice Address - Street 1:2901 E 29TH ST STE 123
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2691
Practice Address - Country:US
Practice Address - Phone:979-776-9400
Practice Address - Fax:979-774-8903
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43963208000000X
TXN0531208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI004000263AOtherHUMANA
WI34156200Medicaid
WI7767338OtherAETNA
WI7767338OtherAETNA
WIBV7508077OtherDEA
WI0063Medicare ID - Type Unspecified