Provider Demographics
NPI:1851492714
Name:VILLARREAL, VICTOR VIDAL (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:VIDAL
Last Name:VILLARREAL
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 1:140 HAVERHILL STREET
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-1504
Mailing Address - Country:US
Mailing Address - Phone:978-475-4202
Mailing Address - Fax:978-475-4393
Practice Address - Street 1:140 HAVERHILL STREET
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-1504
Practice Address - Country:US
Practice Address - Phone:978-475-4202
Practice Address - Fax:978-475-4393
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MA250056208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVE15673Medicare UPIN