Healthcare Provider Details

I. General information

NPI: 1427157254
Provider Name (Legal Business Name): JUANITA C VILLASIS-LOPEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUANITA C LOPEZ

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13833 TAPIA AVE
BAYOU LA BATRE AL
36509-2515
US

IV. Provider business mailing address

13833 TAPIA AVE
BAYOU LA BATRE AL
36509-2515
US

V. Phone/Fax

Practice location:
  • Phone: 251-824-4985
  • Fax: 251-824-4990
Mailing address:
  • Phone: 251-824-4985
  • Fax: 251-824-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number00004405
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: