Provider Demographics
NPI:1548903933
Name:GARCIA VILLEGAS, GONZALO MAURICIO (MD)
Entity type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:MAURICIO
Last Name:GARCIA VILLEGAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GONZALO
Other - Middle Name:MAURICIO
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6420 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1811
Mailing Address - Country:US
Mailing Address - Phone:314-768-8778
Mailing Address - Fax:
Practice Address - Street 1:6420 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-1811
Practice Address - Country:US
Practice Address - Phone:314-768-8778
Practice Address - Fax:314-464-2278
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022020057207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200110389Medicaid