Provider Demographics
NPI:1255389409
Name:VILLAREAL, MANUEL SANTOS (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:SANTOS
Last Name:VILLAREAL
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 1:2830 VICTORY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1785
Mailing Address - Country:US
Mailing Address - Phone:513-585-5504
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:2300 CHAMBER CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:LAKESIDE PARK
Practice Address - State:KY
Practice Address - Zip Code:41017-1686
Practice Address - Country:US
Practice Address - Phone:859-781-4900
Practice Address - Fax:859-572-3039
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30879207RA0201X, 207KA0200X
OH35070669207K00000X, 207RA0201X, 207RG0300X
OH35 070669207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000001005OtherCHA INSURANCE
KY000000033648OtherANTHEM
OH2064564Medicaid
KY610715494OtherOTHER INSURANCE COMPANIES
IN200518220Medicaid
KY138180523662OtherHUMANA INS CO
KY0220092OtherUNITED HEALTH CARE
KY64308794Medicaid
KY650439OtherAETNA
KY0031604Medicare PIN
KY610715494OtherOTHER INSURANCE COMPANIES
KY64308794Medicaid
KY290005747Medicare PIN