Provider Demographics
NPI:1013944602
Name:VILLANUEVA, JOSE (PT)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MED TECH PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4007
Mailing Address - Country:US
Mailing Address - Phone:423-232-6120
Mailing Address - Fax:
Practice Address - Street 1:101 MED TECH PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4007
Practice Address - Country:US
Practice Address - Phone:423-232-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000002402208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0089600OtherBLUE CROSS BLUE SHIELD
TN0089600OtherBLUE CROSS BLUE SHIELD