Provider Demographics
NPI:1962420281
Name:VILLONGCO, RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:VILLONGCO
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 1:121 CEDAR LN
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4457
Mailing Address - Country:US
Mailing Address - Phone:201-836-4228
Mailing Address - Fax:201-357-2150
Practice Address - Street 1:121 CEDAR LN
Practice Address - Street 2:SUITE 2B
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4457
Practice Address - Country:US
Practice Address - Phone:201-836-4228
Practice Address - Fax:201-357-2150
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220788-1207R00000X
NY220788207RG0300X
NJ25MA07738300207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01722150Medicaid
NYG23390Medicare UPIN