Provider Demographics
NPI:1780658773
Name:VILLENA, FELIPE
Entity Type:Individual
Prefix:
First Name:FELIPE
Middle Name:
Last Name:VILLENA
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:6501 COYLE AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0306
Practice Address - Country:US
Practice Address - Phone:916-537-5000
Practice Address - Fax:916-851-2884
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002220A207L00000X
CA20A10074207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0AX100740Medicaid
CA20A100740OtherBLUE SHIELD
CA020A100740Medicare PIN
CA20A100740OtherBLUE SHIELD
CA020A100742Medicare PIN
CA0AX100740Medicaid