Provider Demographics
NPI:1750870754
Name:VILLANUEVA, CRISTAN DALE
Entity type:Individual
Prefix:
First Name:CRISTAN
Middle Name:DALE
Last Name:VILLANUEVA
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 1:9089 CLAIREMONT MESA BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1225
Mailing Address - Country:US
Mailing Address - Phone:858-264-4677
Mailing Address - Fax:
Practice Address - Street 1:9089 CLAIREMONT MESA BLVD
Practice Address - Street 2:STE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1225
Practice Address - Country:US
Practice Address - Phone:858-264-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16985225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA103528349OtherCIGNA