Provider Demographics
NPI:1689279762
Name:VILLAGRA, VICTOR G (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:G
Last Name:VILLAGRA
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 1:76 RIVERVIEW AVENUE
Mailing Address - Street 2:
Mailing Address - City:NOANK
Mailing Address - State:CT
Mailing Address - Zip Code:06340
Mailing Address - Country:US
Mailing Address - Phone:860-614-2563
Mailing Address - Fax:
Practice Address - Street 1:76 RIVERVIEW AVENUE
Practice Address - Street 2:
Practice Address - City:NOANK
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-614-2563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9658112083P0901X
CT0357412083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT965811OtherMEDICAL LICENSE NUMBER