MEDICARE: DR. JUVENTINO VILLANUEVA

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	208000000X	Pediatrics Physician	A46207	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00A462070	OTHER	CA	MEDI-CAL

General Provider Information

NPI Number	:	1164532446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUVENTINO VILLANUEVA

Provider Business Mailing Address
First Line	:	2589 E WASHINGTON BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-1446
Country	:	US
Telephone Number	:	626-798-8792
Fax Number	:	626-798-9607

Provider Business Practice Location Address
First Line	:	6601 RUGBY AVE
Second Line	:	300
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4040
Country	:	US
Telephone Number	:	323-582-1177
Fax Number	:	323-589-2635

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	01/27/2012

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