Provider Demographics
NPI:1639137193
Name:VILLALTA, CARLOS R (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:R
Last Name:VILLALTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3371
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78573-0057
Mailing Address - Country:US
Mailing Address - Phone:956-362-9600
Mailing Address - Fax:956-598-6069
Practice Address - Street 1:202 PALMVIEW DR STE 1
Practice Address - Street 2:
Practice Address - City:PALMVIEW
Practice Address - State:TX
Practice Address - Zip Code:78572-9394
Practice Address - Country:US
Practice Address - Phone:956-225-2625
Practice Address - Fax:956-598-6069
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3646208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE22710Medicare UPIN
TX8030K0Medicare PIN