Provider Demographics
NPI:1770544918
Name:VILLEPONTEAUX, REGINALD DALE (MD)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:DALE
Last Name:VILLEPONTEAUX
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 1:2000 FRONTIS PLAZA BLVD STE 200
Mailing Address - Street 2:ATTN FORSYTH MEDICAL GROUP
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5616
Mailing Address - Country:US
Mailing Address - Phone:336-277-2436
Mailing Address - Fax:
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:ATTN: IPOF
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-718-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30506207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7985078Medicaid
D31111Medicare UPIN
NC204143BMedicare ID - Type Unspecified