Provider Demographics
NPI:1154446425
Name:INFECTIOUS DISEASE MEDICAL GROUP
Entity type:Organization
Organization Name:INFECTIOUS DISEASE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BENEDICT
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-867-3829
Mailing Address - Street 1:5601 NORRIS CANYON RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-5407
Mailing Address - Country:US
Mailing Address - Phone:925-867-3829
Mailing Address - Fax:925-867-3820
Practice Address - Street 1:5601 NORRIS CANYON RD
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5407
Practice Address - Country:US
Practice Address - Phone:925-867-3829
Practice Address - Fax:925-867-3820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61699207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG76577Medicare UPIN