Provider Demographics
NPI:1932118353
Name:VILLANUEVA, ETHEL L (MD)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:L
Last Name:VILLANUEVA
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 1:5528 METROPOLITAN PKWY
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4105
Mailing Address - Country:US
Mailing Address - Phone:586-795-3232
Mailing Address - Fax:586-795-5540
Practice Address - Street 1:5528 METROPOLITAN PKWY
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4105
Practice Address - Country:US
Practice Address - Phone:586-795-3232
Practice Address - Fax:586-795-5540
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045387208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1445368Medicaid
05053053351Medicare ID - Type Unspecified
MIE86110Medicare UPIN