Healthcare Provider Details

I. General information

NPI: 1962889832
Provider Name (Legal Business Name): CAMILO VILLALOBOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 10/20/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-19 QUEENS BLVD CITY MD
ELMHURST NY
11373-5531
US

IV. Provider business mailing address

91-19 QUEENS BLVD CITY MD
ELMHURST NY
11373-5531
US

V. Phone/Fax

Practice location:
  • Phone: 646-647-1253
  • Fax: 718-452-6112
Mailing address:
  • Phone: 646-647-1253
  • Fax: 718-452-6112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number296179
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: