Basic Information
| Provider Information | |||||||||
| NPI: | 1538153093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLARREAL | ||||||||
| FirstName: | ENRIQUE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1458 | ||||||||
| Address2: | |||||||||
| City: | KAILUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967341458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082861961 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 875 WAIMANU ST | ||||||||
| Address2: | STE 614 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968135267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085333936 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0805X | MD12543 | HI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0805X | ME8919 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 270914700 | 05 | FL | MEDICAID |