Provider Demographics
NPI:1912972241
Name:VILLANUEVA, THELMA L (MD)
Entity Type:Individual
Prefix:
First Name:THELMA
Middle Name:L
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THELMA
Other - Middle Name:C
Other - Last Name:LAZARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:525 HIGHWAY 70
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723
Mailing Address - Country:US
Mailing Address - Phone:732-920-2424
Mailing Address - Fax:732-920-1211
Practice Address - Street 1:525 HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723
Practice Address - Country:US
Practice Address - Phone:732-920-2424
Practice Address - Fax:732-920-1211
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02883300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2524007Medicaid