1568454205 NPI number — ROLLO P VILLAREAL MD

Table of content: ROLLO P VILLAREAL MD (NPI 1568454205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568454205 NPI number — ROLLO P VILLAREAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VILLAREAL
Provider First Name:
ROLLO
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568454205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 EPTING AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29646-4041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-227-6818
Provider Business Mailing Address Fax Number:
864-227-0850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
421 EPTING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29646-4041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-227-6818
Provider Business Practice Location Address Fax Number:
864-227-0850
Provider Enumeration Date:
08/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0001X , with the licence number:  23754 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X , with the licence number: 23754 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: T79233 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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