Healthcare Provider Details

I. General information

NPI: 1538185764
Provider Name (Legal Business Name): DENNIS T VILLAREAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4488 FOREST PARK AVE STE 201
SAINT LOUIS MO
63108-2215
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8031
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-2715
  • Fax: 314-286-2701
Mailing address:
  • Phone: 314-286-2715
  • Fax: 314-286-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number102107
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: