Basic Information
| Provider Information | |||||||||
| NPI: | 1083666234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VILLANUEVA | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6027 WALNUT GROVE | ||||||||
| Address2: | SUITE 317 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018183921 | ||||||||
| FaxNumber: | 9017673056 | ||||||||
| Practice Location | |||||||||
| Address1: | 6027 WALNUT GROVE | ||||||||
| Address2: | SUITE 317 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018183921 | ||||||||
| FaxNumber: | 9017673056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 05/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 39777 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3335228 | 05 | TN | MEDICAID |