Provider Demographics
NPI:1215099668
Name:CAMPOS, MINERVA VILLARREAL (MD)
Entity type:Individual
Prefix:
First Name:MINERVA
Middle Name:VILLARREAL
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 INGOMAR ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20015-1929
Mailing Address - Country:US
Mailing Address - Phone:202-237-2267
Mailing Address - Fax:
Practice Address - Street 1:3020 14TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-6865
Practice Address - Country:US
Practice Address - Phone:202-612-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD035435207Q00000X
TXK9030207Q00000X
CAG47212207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A92710Medicare UPIN