MEDICARE: RAISSA VILLANUEVA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	2084N0400X	Neurology Physician	254706	NY

General Provider Information

NPI Number	:	1013027135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAISSA VILLANUEVA MD

Provider Business Mailing Address
First Line	:	PO BOX 278984
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14627-8984
Country	:	US
Telephone Number	:	585-341-7500
Fax Number	:	585-341-7510

Provider Business Practice Location Address
First Line	:	919 WESTFALL RD
Second Line	:	BUILDING C, STE 220
City	:	ROCHESTER
State	:	NY
Zip	:	14618-2628
Country	:	US
Telephone Number	:	585-341-7500
Fax Number	:	585-341-7510

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/06/2023

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