Provider Demographics
NPI:1609859206
Name:VILLAVICENCIO, JUAN B (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:B
Last Name:VILLAVICENCIO
Suffix:
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:PO BOX 4960
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-4960
Mailing Address - Country:US
Mailing Address - Phone:787-396-6658
Mailing Address - Fax:787-852-8248
Practice Address - Street 1:HOSPITAL RYDER MEMORIAL
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00792
Practice Address - Country:US
Practice Address - Phone:787-852-0768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8317207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR82349OtherTRIPLE S
PR6240098OtherHUMANA HEALTH PLANS
PR82349OtherMEDICARE OPTIMO
PR6240098OtherHUMANA INSURANCE
PR3549OtherPREFFERED MEDICARE CHOICE
PR6240098OtherHUMANA GOLD CHOICE
PR060172OtherCRUZ AZUL
PR10381OtherINTERNATIONAL MEDICAL CAR
PR992181OtherMEDICARE Y MUCHO MAS
PR6240098OtherHUMANA HEALTH PLANS
PRF08092Medicare UPIN