Provider Demographics
NPI:1679374979
Name:VILLAVICENCIO, GABRIEL LEO (MD)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:LEO
Last Name:VILLAVICENCIO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 S JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-4072
Mailing Address - Country:US
Mailing Address - Phone:303-378-0208
Mailing Address - Fax:
Practice Address - Street 1:4505 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89154-9900
Practice Address - Country:US
Practice Address - Phone:702-855-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-22
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty