Provider Demographics
NPI:1205899606
Name:VILLANUEVA, ENGRACIO GARY (MD)
Entity type:Individual
Prefix:
First Name:ENGRACIO
Middle Name:GARY
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 1:89-06 135TH ST
Mailing Address - Street 2:7L
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11418
Mailing Address - Country:US
Mailing Address - Phone:718-206-6984
Mailing Address - Fax:718-206-6786
Practice Address - Street 1:3080 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208
Practice Address - Country:US
Practice Address - Phone:718-647-0240
Practice Address - Fax:718-277-8203
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113865207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY652631Medicare ID - Type Unspecified
B17549Medicare UPIN