Provider Demographics
NPI:1457532632
Name:MANUEL B. VILLANUEVA M.D., P.C.
Entity Type:Organization
Organization Name:MANUEL B. VILLANUEVA M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-877-2600
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25818-0265
Mailing Address - Country:US
Mailing Address - Phone:304-877-2600
Mailing Address - Fax:304-877-2600
Practice Address - Street 1:6070 ROBERT C BYRD DR
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:WV
Practice Address - Zip Code:25818
Practice Address - Country:US
Practice Address - Phone:304-877-2600
Practice Address - Fax:304-877-2600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV410013738OtherRAILROAD MEDICARE
WV0056004000Medicaid
WV410013738OtherRAILROAD MEDICARE
WV9195181Medicare PIN