Provider Demographics
NPI:1972768273
Name:VILLANUEVA, JUSTO H (MD)
Entity Type:Individual
Prefix:
First Name:JUSTO
Middle Name:H
Last Name:VILLANUEVA
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 1:4201 PALM AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-4424
Mailing Address - Country:US
Mailing Address - Phone:305-823-0210
Mailing Address - Fax:305-823-0096
Practice Address - Street 1:4201 PALM AVE
Practice Address - Street 2:SUITE C
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4424
Practice Address - Country:US
Practice Address - Phone:305-823-0210
Practice Address - Fax:305-823-0096
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71662208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME71662OtherFLORIDA LICENSE