Provider Demographics
NPI:1174561401
Name:VILLANUEVA, BENITO (MD)
Entity type:Individual
Prefix:
First Name:BENITO
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1224
Mailing Address - Country:US
Mailing Address - Phone:858-550-4954
Mailing Address - Fax:858-550-4946
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-550-4954
Practice Address - Fax:858-550-4946
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA26716207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26-2105023OtherTAX ID
A24930Medicare UPIN
CA26-2105023OtherTAX ID