Provider Demographics
NPI:1255999744
Name:VILLAROSA, NEIL DOMINIC SENO
Entity type:Individual
Prefix:
First Name:NEIL DOMINIC
Middle Name:SENO
Last Name:VILLAROSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7313 WOODWARD AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2549
Mailing Address - Country:US
Mailing Address - Phone:630-915-4474
Mailing Address - Fax:
Practice Address - Street 1:7313 WOODWARD AVE APT 301
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2549
Practice Address - Country:US
Practice Address - Phone:630-915-4474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021740208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV462-6248-6043Medicaid