Basic Information
| Provider Information | |||||||||
| NPI: | 1043485139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE VILLA | ||||||||
| FirstName: | VICTOR ADALBERT | ||||||||
| MiddleName: | GERALDEZ | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 S VANBUREN ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543013538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204336050 | ||||||||
| FaxNumber: | 9204336049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 03/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 4301114122 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | 24449 | NE | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | P00705495 | 01 | NE | RAILROAD MEDICARE | OTHER | 10026169400 | 05 | NE | MEDICAID | 10026133000 | 05 | NE | MEDICAID |