Provider Demographics
NPI:1760630628
Name:RANDY VILLANUEVA MD PC
Entity type:Organization
Organization Name:RANDY VILLANUEVA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY JOSEPH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-590-0103
Mailing Address - Street 1:3025 N WINDSTONE WAY LN
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-7383
Mailing Address - Country:US
Mailing Address - Phone:901-590-0103
Mailing Address - Fax:
Practice Address - Street 1:3025 N WINDSTONE WAY LN
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-7383
Practice Address - Country:US
Practice Address - Phone:901-590-0103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39777207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN39777OtherMD LICENSE
TN39777OtherMD LICENSE