Provider Demographics
NPI:1427157254
Name:VILLASIS-LOPEZ, JUANITA C (MD)
Entity type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:C
Last Name:VILLASIS-LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JUANITA
Other - Middle Name:C
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13833 TAPIA AVE
Mailing Address - Street 2:
Mailing Address - City:BAYOU LA BATRE
Mailing Address - State:AL
Mailing Address - Zip Code:36509-2515
Mailing Address - Country:US
Mailing Address - Phone:251-824-4985
Mailing Address - Fax:251-824-4990
Practice Address - Street 1:13833 TAPIA AVE
Practice Address - Street 2:
Practice Address - City:BAYOU LA BATRE
Practice Address - State:AL
Practice Address - Zip Code:36509-2515
Practice Address - Country:US
Practice Address - Phone:251-824-4985
Practice Address - Fax:251-824-4990
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00004405207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D83843Medicare UPIN
AL61200LOPMedicare ID - Type Unspecified