Healthcare Provider Details

I. General information

NPI: 1962724609
Provider Name (Legal Business Name): MANUEL VILLAVERDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13707 SW 152ND ST
MIAMI FL
33177
US

IV. Provider business mailing address

13707 SW 152ND ST
MIAMI FL
33177-1106
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-9200
  • Fax:
Mailing address:
  • Phone: 305-585-9210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 106122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: