Provider Demographics
NPI:1902994551
Name:VILLALVAZO, HUMBERTO JESUS (MD)
Entity type:Individual
Prefix:DR
First Name:HUMBERTO
Middle Name:JESUS
Last Name:VILLALVAZO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:HUMBERTO
Other - Middle Name:JESUS
Other - Last Name:VILLALVAZO-CAMACHO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2570 NW EDENBOWER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6214
Mailing Address - Country:US
Mailing Address - Phone:541-677-7200
Mailing Address - Fax:541-229-3309
Practice Address - Street 1:1937 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2720
Practice Address - Country:US
Practice Address - Phone:541-677-7200
Practice Address - Fax:541-229-3309
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD224112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABV9097519OtherDEA
CABV9097519OtherDEA