=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255389409
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANUEL SANTOS VILLAREAL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 04/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 CHAMBER CENTER DR STE 102
-----------------------------------------------------
City | LAKESIDE PARK
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41017-1686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-781-4900
-----------------------------------------------------
Fax | 859-572-3039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2830 VICTORY PKWY
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45206-1785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-585-5504
-----------------------------------------------------
Fax | 513-585-5511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0201X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology (Internal Medicine) Physician
-----------------------------------------------------
License Number | 30879
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number | 35070669
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207KA0200X
-----------------------------------------------------
Taxonomy Name | Allergy Physician
-----------------------------------------------------
License Number | 30879
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RA0201X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology (Internal Medicine) Physician
-----------------------------------------------------
License Number | 35070669
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207RA0201X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology (Internal Medicine) Physician
-----------------------------------------------------
License Number | 35 070669
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 35070669
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------