Basic Information
| Provider Information | |||||||||
| NPI: | 1386704914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLANOS | ||||||||
| FirstName: | MA. THERESA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 RAYNOLDS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799051613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152154480 | ||||||||
| FaxNumber: | 9152155386 | ||||||||
| Practice Location | |||||||||
| Address1: | 4801 ALBERTA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152155700 | ||||||||
| FaxNumber: | 9152158697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | M5564 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 181613401 | 05 | TX | MEDICAID | 8H0439 | 01 | TX | BCBS OF TEXAS | OTHER | S0149254 | 01 | TX | DPS REGISTRATION NUMBER | OTHER |