Provider Demographics
NPI:1720033939
Name:VILLAVICENCIO, ALAN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:THOMAS
Last Name:VILLAVICENCIO
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 9049
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-9049
Mailing Address - Country:US
Mailing Address - Phone:303-938-5700
Mailing Address - Fax:303-998-0007
Practice Address - Street 1:4743 ARAPAHOE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1113
Practice Address - Country:US
Practice Address - Phone:303-938-5700
Practice Address - Fax:303-998-0007
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR40687207T00000X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC441038Medicare PIN
COC474258Medicare PIN
H52216Medicare UPIN