Basic Information
| Provider Information | |||||||||
| NPI: | 1710207378 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VILLEGAS | ||||||||
| FirstName: | GUSTAVO | ||||||||
| MiddleName: | V. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2603 MICHAEL ANGELO DR | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785391417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563628767 | ||||||||
| FaxNumber: | 9563622548 | ||||||||
| Practice Location | |||||||||
| Address1: | 2603 MICHAEL ANGELO DR | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785391417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563628767 | ||||||||
| FaxNumber: | 9563622548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2010 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
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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 | 208800000X | Q5296 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 349165602 | 05 | TX | MEDICAID | 349165601 | 05 | TX | MEDICAID |