Provider Demographics
NPI:1609120666
Name:VILLANUEVA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:VILLANUEVA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-271-0135
Mailing Address - Street 1:1451 NE 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1033
Mailing Address - Country:US
Mailing Address - Phone:954-271-0135
Mailing Address - Fax:954-271-0135
Practice Address - Street 1:1451 NE 4TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1033
Practice Address - Country:US
Practice Address - Phone:954-271-0135
Practice Address - Fax:954-271-0135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98244207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME98244OtherSTATE LICENSE
FLGV821AMedicare UPIN