Healthcare Provider Details

I. General information

NPI: 1780704734
Provider Name (Legal Business Name): CARLOS ALFONSO VILLANUEVA DEL RIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 E CAMBRIDGE AVE STE 302
PHOENIX AZ
85006-1464
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2327
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-5200
  • Fax: 602-933-4272
Mailing address:
  • Phone: 602-933-1813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number26995
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number57907
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: