Healthcare Provider Details

I. General information

NPI: 1437562097
Provider Name (Legal Business Name): ROGER VILLANUEVA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PARADISE RD STE E
MODESTO CA
95351-3163
US

IV. Provider business mailing address

1441 FLORIDA AVE
MODESTO CA
95350-4404
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-3526
  • Fax:
Mailing address:
  • Phone: 209-576-3576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: