Provider Demographics
NPI:1801974084
Name:DE FOREST, IMELDA (MD)
Entity type:Individual
Prefix:DR
First Name:IMELDA
Middle Name:
Last Name:DE FOREST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:IMELDA
Other - Middle Name:
Other - Last Name:VILLANUEVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 N ROSE AVE STE 280
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-7645
Practice Address - Country:US
Practice Address - Phone:805-384-8071
Practice Address - Fax:805-278-6477
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51405208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF88083Medicare UPIN