Provider Demographics
NPI:1881034395
Name:VILLAVICENCIO, SANDRA (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:VILLAVICENCIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4875 MAXWELL AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-1559
Mailing Address - Country:US
Mailing Address - Phone:915-533-7057
Mailing Address - Fax:
Practice Address - Street 1:4774 LOMA DEL SUR DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79934-3597
Practice Address - Country:US
Practice Address - Phone:915-533-7057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7502207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine