Provider Demographics
NPI:1598071987
Name:VILLALOBOS, MIGUEL ANGEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:ANGEL
Last Name:VILLALOBOS
Suffix:JR
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 1:3 COOPER PLZ
Mailing Address - Street 2:SUITE 411
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1438
Mailing Address - Country:US
Mailing Address - Phone:856-342-3012
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251072086S0129X
PAMT198237208600000X
PA1598071987208600000X
NJ25MA09873900208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS25107Medicaid