Healthcare Provider Details

I. General information

NPI: 1588684062
Provider Name (Legal Business Name): JAMES M VILLAREAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/01/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE N12 AND N7
FORT DEFIANCE AZ
86504-0649
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8132
  • Fax:
Mailing address:
  • Phone: 801-269-2500
  • Fax: 801-269-2696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number275346-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number275346-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: