=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437732666
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON VILLASENOR DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2021
-----------------------------------------------------
Last Update Date | 12/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 W PARK ST
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61801-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-383-3240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5855 S QUARTERLINE RD APT 412
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-7907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-280-4128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 5151015206
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------