Provider Demographics
NPI:1609986942
Name:VILLANUEVA, PEDRO RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:RAFAEL
Last Name:VILLANUEVA
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 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-316-5800
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:7364 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-7220
Practice Address - Country:US
Practice Address - Phone:757-345-0011
Practice Address - Fax:757-534-0381
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049988207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6017380Medicaid
VA6017380Medicaid
VA0454699Medicare ID - Type Unspecified