Provider Demographics
NPI:1881679512
Name:VILLALBA, RENDUELES II (MD)
Entity type:Individual
Prefix:
First Name:RENDUELES
Middle Name:
Last Name:VILLALBA
Suffix:II
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 1:593 EDDY ST
Mailing Address - Street 2:APC 978
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-4318
Mailing Address - Fax:401-444-7865
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:POTTER 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-2128
Practice Address - Fax:401-444-8836
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD089972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006033Medicaid
007007270Medicare ID - Type Unspecified
G21438Medicare UPIN