Healthcare Provider Details

I. General information

NPI: 1740447200
Provider Name (Legal Business Name): GUSTAVO ADOLFO VILLALONA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

2220 SARAGOSSA AVE
JACKSONVILLE FL
32217-2684
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3600
  • Fax:
Mailing address:
  • Phone: 917-291-7654
  • Fax: 833-411-0563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberME143331
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: