Provider Demographics
NPI:1649227653
Name:VILLARREAL, GUSTAVO E (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:E
Last Name:VILLARREAL
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-606-6400
Mailing Address - Fax:903-606-1522
Practice Address - Street 1:2510 E MAIN ST STE 108
Practice Address - Street 2:
Practice Address - City:ALICE
Practice Address - State:TX
Practice Address - Zip Code:78332-4188
Practice Address - Country:US
Practice Address - Phone:361-661-8105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6038207Q00000X
TX742380876174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079740902Medicaid
TX079740901Medicaid
TX00061NMedicare PIN
TX079740901Medicaid