Provider Demographics
NPI:1679592927
Name:VILLANUEVA, PHILLIP A (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:A
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-7200
Mailing Address - Fax:215-707-3831
Practice Address - Street 1:3509 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4105
Practice Address - Country:US
Practice Address - Phone:215-707-7200
Practice Address - Fax:215-707-3831
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD433039207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0670723-00Medicaid
FLD64831Medicare UPIN