Healthcare Provider Details

I. General information

NPI: 1942525332
Provider Name (Legal Business Name): NICHOLAS VILLALON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NICHOLAS ROGER VILLALON MD

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQEURQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1125
  • Fax: 505-841-1737
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM-1995
License Number StateGU
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2023-0649
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0598
License Number StateMP
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number60459537
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD193115
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: