Healthcare Provider Details

I. General information

NPI: 1568853760
Provider Name (Legal Business Name): LUIS S VILELLA-GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: LUIS S VILELLA M.D.

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4671 38TH ST S
FARGO ND
58104-7866
US

IV. Provider business mailing address

1776 WOODSTEAD CT STE 208
THE WOODLANDS TX
77380-1480
US

V. Phone/Fax

Practice location:
  • Phone: 877-749-7428
  • Fax:
Mailing address:
  • Phone: 877-749-7428
  • Fax: 512-628-3314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD2005-0853
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number9273
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: