Provider Demographics
NPI:1760479935
Name:VILLALOBOS, ELISEO M (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISEO
Middle Name:M
Last Name:VILLALOBOS
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 1:4456 LOCKHILL SELMA RD STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-3993
Mailing Address - Country:US
Mailing Address - Phone:210-455-2000
Mailing Address - Fax:210-957-2227
Practice Address - Street 1:4456 LOCKHILL SELMA RD STE 103
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3993
Practice Address - Country:US
Practice Address - Phone:210-442-8891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2041207KA0200X
TXL2042207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01851429Medicaid
PA01851429Medicaid
050562Medicare ID - Type Unspecified