Healthcare Provider Details

I. General information

NPI: 1619985215
Provider Name (Legal Business Name): BRANDON LUCAS VILLARREAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18300 ROSCOE BLVD
NORTHRIDGE CA
91325
US

IV. Provider business mailing address

PO BOX 7001
TARZANA CA
91357-7001
US

V. Phone/Fax

Practice location:
  • Phone: 818-885-8500
  • Fax:
Mailing address:
  • Phone: 818-888-7815
  • Fax: 818-715-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG60466
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: