Healthcare Provider Details

I. General information

NPI: 1902571532
Provider Name (Legal Business Name): ANDRES R VILLAR MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 11TH ST SW
LIVE OAK FL
32064-3606
US

IV. Provider business mailing address

PO BOX 606
GLEN ST MARY FL
32040-0606
US

V. Phone/Fax

Practice location:
  • Phone: 386-364-8050
  • Fax:
Mailing address:
  • Phone: 386-755-5044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDRES R VILLAR
Title or Position: ADMINISTRATOR
Credential: MD
Phone: 386-755-5044