Healthcare Provider Details

I. General information

NPI: 1922018647
Provider Name (Legal Business Name): GLEN VILLANUEVA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 B ST
LIVINGSTON CA
95334-9593
US

IV. Provider business mailing address

600 B ST
LIVINGSTON CA
95334-9593
US

V. Phone/Fax

Practice location:
  • Phone: 209-850-3500
  • Fax: 209-850-3499
Mailing address:
  • Phone: 209-850-3500
  • Fax: 209-850-3499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A6969
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: