MEDICARE: DR. CARLOS R VILLALTA 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	208D00000X	General Practice Physician	J3646	TX

General Provider Information

NPI Number	:	1639137193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLOS R VILLALTA MD

Provider Business Mailing Address
First Line	:	PO BOX 3371
Second Line	:
City	:	MISSION
State	:	TX
Zip	:	78573-0057
Country	:	US
Telephone Number	:	956-362-9600
Fax Number	:	956-598-6069

Provider Business Practice Location Address
First Line	:	202 PALMVIEW DR STE 1
Second Line	:
City	:	PALMVIEW
State	:	TX
Zip	:	78572-9394
Country	:	US
Telephone Number	:	956-225-2625
Fax Number	:	956-598-6069

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	11/04/2022

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