Provider Demographics
NPI:1477673762
Name:VILLANUEVA GONZALEZ, WANDA I (MD)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:I
Last Name:VILLANUEVA GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 2 BOX 6355
Mailing Address - Street 2:
Mailing Address - City:BAJADERO
Mailing Address - State:PR
Mailing Address - Zip Code:00616-9760
Mailing Address - Country:US
Mailing Address - Phone:407-593-0918
Mailing Address - Fax:
Practice Address - Street 1:1305 N ORANGE AVE
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-2547
Practice Address - Country:US
Practice Address - Phone:904-284-5904
Practice Address - Fax:904-284-5905
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14440208D00000X
FLACN706208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIH341ZOtherFLORIFA MEDICARE
FL015593700Medicaid
FL015593700Medicaid