Healthcare Provider Details

I. General information

NPI: 1124216601
Provider Name (Legal Business Name): EDWIN M VILLALOBOS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 E ALTAMONTE DR SUITE 231
ALTAMONTE SPRINGS FL
32701-5105
US

IV. Provider business mailing address

661 E ALTAMONTE DR SUITE 231
ALTAMONTE SPRINGS FL
32701-5105
US

V. Phone/Fax

Practice location:
  • Phone: 407-331-0771
  • Fax: 407-331-0577
Mailing address:
  • Phone: 407-331-0771
  • Fax: 407-331-0577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9101382
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME44332
License Number StateFL

VIII. Authorized Official

Name: DR. EDWIN M. VILLALOBOS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 407-331-0771