Provider Demographics
NPI:1679916076
Name:VILLASENOR, RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:VILLASENOR
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 1:10520 CAMARILLO ST.
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602
Mailing Address - Country:US
Mailing Address - Phone:818-762-4028
Mailing Address - Fax:818-762-4028
Practice Address - Street 1:10520 CAMARILLO ST
Practice Address - Street 2:
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602
Practice Address - Country:US
Practice Address - Phone:818-762-4028
Practice Address - Fax:818-762-4028
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAV1071036207W00000X
CAA21201207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology