Healthcare Provider Details

I. General information

NPI: 1033783923
Provider Name (Legal Business Name): SELVIN VILLEDA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 N FRANKFORD AVE
LUBBOCK TX
79416-1545
US

IV. Provider business mailing address

2215 NASHVILLE AVE
LUBBOCK TX
79410-1105
US

V. Phone/Fax

Practice location:
  • Phone: 806-725-5480
  • Fax: 806-723-6156
Mailing address:
  • Phone: 806-725-5228
  • Fax: 806-723-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberV0572
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: