Basic Information
| Provider Information | |||||||||
| NPI: | 1306814090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLAHERMOSA | ||||||||
| FirstName: | JUANITO | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 803 HWY 71 WEST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644851151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063243121 | ||||||||
| FaxNumber: | 8163243122 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 HWY 71 WEST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 644851151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063243121 | ||||||||
| FaxNumber: | 8163243122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 06/19/2009 | ||||||||
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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 | 208D00000X | 32529 | MO | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | BV2666115 | 01 | DEA | OTHER | 200349546 | 05 | MO | MEDICAID |