Healthcare Provider Details

I. General information

NPI: 1316400534
Provider Name (Legal Business Name): MATEO VILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2019
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11750 BIRD RD
MIAMI FL
33175-3530
US

IV. Provider business mailing address

1859 AMERICAN WAY
LAWRENCEVILLE GA
30043-6614
US

V. Phone/Fax

Practice location:
  • Phone: 305-223-2000
  • Fax:
Mailing address:
  • Phone: 404-202-3261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDR.0073680
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: