Basic Information
Provider Information | |||||||||
NPI: | 1689859266 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VILLAREAL | ||||||||
FirstName: | RONALD | ||||||||
MiddleName: | DELA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1129 NORTHERN BLVD | ||||||||
Address2: | STE. 101 | ||||||||
City: | MANHASSET | ||||||||
State: | NY | ||||||||
PostalCode: | 110303045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5163655570 | ||||||||
FaxNumber: | 5163655532 | ||||||||
Practice Location | |||||||||
Address1: | 1129 NORTHERN BLVD | ||||||||
Address2: | 101 | ||||||||
City: | MANHASSET | ||||||||
State: | NY | ||||||||
PostalCode: | 110303045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5163655570 | ||||||||
FaxNumber: | 5163655532 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2008 | ||||||||
LastUpdateDate: | 07/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 99052287A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | 01071586 | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RN0300X | 263968 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 2010864902 | 05 | IN |   | MEDICAID |