Provider Demographics
NPI:1699729335
Name:VILLACARLOS, DOLORES A (MD)
Entity type:Individual
Prefix:DR
First Name:DOLORES
Middle Name:A
Last Name:VILLACARLOS
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 1:2040 PACIFIC COAST HWY STE S
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-2660
Mailing Address - Country:US
Mailing Address - Phone:424-347-8008
Mailing Address - Fax:844-481-9664
Practice Address - Street 1:2040 PACIFIC COAST HWY STE S
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-2660
Practice Address - Country:US
Practice Address - Phone:424-347-8008
Practice Address - Fax:844-481-9664
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35717Medicaid
WA35717GMedicare ID - Type Unspecified
CAA35717Medicaid