Healthcare Provider Details

I. General information

NPI: 1356315626
Provider Name (Legal Business Name): MARIANO VILLALON TOLENTINO JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 E EMPIRE ST
BLOOMINGTON IL
61704-3738
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-3380
  • Fax: 309-661-3318
Mailing address:
  • Phone: 309-661-3380
  • Fax: 309-661-3318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036075928
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: