Provider Demographics
NPI:1720314362
Name:VILLARREAL, JORGE (LSA)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:
Last Name:VILLARREAL
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 SHAFTSBURY DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78415-4483
Mailing Address - Country:US
Mailing Address - Phone:361-459-9680
Mailing Address - Fax:
Practice Address - Street 1:2425 SHAFTSBURY DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-4483
Practice Address - Country:US
Practice Address - Phone:361-459-9680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-01
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00550246ZC0007X
363AS0400X
TX3323246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXSA00550OtherTEXAS MEDICAL BOARD
TX8KC993OtherBCBS - XCITE SURGICAL
TX8KC992OtherBCBS - UNIVERSAL SURGICAL PARTNERS
TX8KC994OtherBCBS - UNIVERSAL SURGICAL ASSISTANTS INC
TX8LH882OtherBCBS - BLUE STAR SURGICAL ASSISTANTS LLC