Basic Information
| Provider Information | |||||||||
| NPI: | 1164875902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ VILLALBA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | ADOLFO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2168 | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293042168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645604304 | ||||||||
| FaxNumber: | 8645604413 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 W SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | UNION | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293792839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644298029 | ||||||||
| FaxNumber: | 8644293515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2016 | ||||||||
| LastUpdateDate: | 09/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | D0091283 | MD | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | DR.0062854 | CO | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 86507 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 865077 | 05 | SC | MEDICAID | SCL150H888 | 01 | SC | MEDICARE PIN | OTHER |