MEDICARE: ALTUS NEUROLOGY P C

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	2084N0400X	Neurology Physician

General Provider Information

NPI Number	:	1780721779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTUS NEUROLOGY P C

Provider Business Mailing Address
First Line	:	PO BOX 1137
Second Line	:
City	:	ALTUS
State	:	OK
Zip	:	73522-1137
Country	:	US
Telephone Number	:	580-481-2325
Fax Number	:	580-482-0091

Provider Business Practice Location Address
First Line	:	219 E COMMERCE ST
Second Line	:
City	:	ALTUS
State	:	OK
Zip	:	73521-3913
Country	:	US
Telephone Number	:	580-481-2325
Fax Number	:	580-482-0091

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JUAN RUBEN VILLAZON
Credential	:	M.D.
Telephone Number	:	580-481-2325

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	12/17/2012

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