Provider Demographics
NPI:1689772261
Name:VILLALVAZO, ANTONIO
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:VILLALVAZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6191 N FRESNO ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8612
Mailing Address - Country:US
Mailing Address - Phone:559-227-1663
Mailing Address - Fax:559-227-9083
Practice Address - Street 1:6191 N FRESNO ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8612
Practice Address - Country:US
Practice Address - Phone:559-227-1663
Practice Address - Fax:559-227-9083
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5430437Medicaid
CA5430437Medicaid
CA5430437Medicaid
CA030608632OtherTIN