Basic Information
| Provider Information | |||||||||
| NPI: | 1609871821 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VILLARREAL | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11955 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383080132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316647395 | ||||||||
| FaxNumber: | 7316640057 | ||||||||
| Practice Location | |||||||||
| Address1: | 395 HOSPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383052080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316647395 | ||||||||
| FaxNumber: | 7316640057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 01/08/2013 | ||||||||
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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 | 208600000X | 26380 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5969342 | 01 | TN | AETNA | OTHER | 3060477 | 01 | TN | BLUE CROSS OF TN | OTHER | 3089277 | 05 | TN | MEDICAID | 020033489 | 01 | TN | RAILROAD MEDICARE | OTHER |