Healthcare Provider Details

I. General information

NPI: 1629092564
Provider Name (Legal Business Name): MARIVIC DELOS REYES VILLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39512 WOODGATE LN
LADY LAKE FL
32159-3350
US

IV. Provider business mailing address

1507 BUENOS AIRES BLVD
THE VILLAGES FL
32159-8974
US

V. Phone/Fax

Practice location:
  • Phone: 352-630-0108
  • Fax: 352-307-8442
Mailing address:
  • Phone: 352-561-6299
  • Fax: 352-750-8032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME68756
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME68756
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: