Provider Demographics
NPI:1609871821
Name:VILLARREAL, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:VILLARREAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11955
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0132
Mailing Address - Country:US
Mailing Address - Phone:731-664-7395
Mailing Address - Fax:731-664-0057
Practice Address - Street 1:395 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2080
Practice Address - Country:US
Practice Address - Phone:731-664-7395
Practice Address - Fax:731-664-0057
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26380208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5969342OtherAETNA
TN3060477OtherBLUE CROSS OF TN
TN3089277Medicaid
TN020033489OtherRAILROAD MEDICARE
TNE68846Medicare UPIN
TN3089277Medicaid