Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204F00000X | Transplant Surgeon | 264532 | MA |
Y | 208G00000X | Cardiothoracic Vascular Surgeon | 1015 | MN |
N | 208G00000X | Cardiothoracic Vascular Surgeon | 264532 | MA |
NPI | 1497153332 |
---|---|
Provider Name | Mauricio Alejandro Villavicencio Theoduloz |
First Address | Rochester, MN 55905-0001 |
Second Address | Rochester, MN 55905-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2014 |
Last Update Date | 25/01/2021 |