Healthcare Provider Details

I. General information

NPI: 1376460444
Provider Name (Legal Business Name): MATIAS ANTONIO ANDRADE VILLALOBOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0002
US

IV. Provider business mailing address

12 TALCOTT FOREST RD APT A
FARMINGTON CT
06032-3575
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2000
  • Fax:
Mailing address:
  • Phone: 959-590-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number390200000X
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: