Provider Demographics
NPI:1922018647
Name:VILLANUEVA, GLEN (DO)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 B ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-9593
Mailing Address - Country:US
Mailing Address - Phone:209-850-3500
Mailing Address - Fax:209-850-3499
Practice Address - Street 1:600 B ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-9593
Practice Address - Country:US
Practice Address - Phone:209-850-3500
Practice Address - Fax:209-850-3499
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6969207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00AX69690Medicare ID - Type UnspecifiedMCR INDIVIDUAL
G17188Medicare UPIN