Healthcare Provider Details

I. General information

NPI: 1912972241
Provider Name (Legal Business Name): THELMA L VILLANUEVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: THELMA C LAZARO

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 HIGHWAY 70
BRICK NJ
08723
US

IV. Provider business mailing address

525 HIGHWAY 70
BRICK NJ
08723
US

V. Phone/Fax

Practice location:
  • Phone: 732-920-2424
  • Fax: 732-920-1211
Mailing address:
  • Phone: 732-920-2424
  • Fax: 732-920-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA02883300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: