Provider Demographics
NPI:1780232033
Name:VILLANUEVA MATOS, ISRAEL J (MD)
Entity Type:Individual
Prefix:
First Name:ISRAEL
Middle Name:J
Last Name:VILLANUEVA MATOS
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:B5 URB SAN CRISTOBAL
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-2692
Mailing Address - Country:US
Mailing Address - Phone:787-868-2803
Mailing Address - Fax:
Practice Address - Street 1:B5 URB SAN CRISTOBAL
Practice Address - Street 2:
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602-2692
Practice Address - Country:US
Practice Address - Phone:787-868-2803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21548208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice