Healthcare Provider Details

I. General information

NPI: 1558432997
Provider Name (Legal Business Name): CARMEN VANESSA VILLABONA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date: 09/27/2019
Reactivation Date: 10/03/2019

III. Provider practice location address

1475 NW 12TH AVE
MIAMI FL
33136-1002
US

IV. Provider business mailing address

1475 NW 12TH AVE
MIAMI FL
33136-1002
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-3636
  • Fax: 305-243-6575
Mailing address:
  • Phone: 305-243-3636
  • Fax: 305-243-6575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME101645
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME101645
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: