Healthcare Provider Details

I. General information

NPI: 1801939277
Provider Name (Legal Business Name): VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 WEDGEWOOD LN
THE VILLAGES FL
32162-7181
US

IV. Provider business mailing address

3351 WEDGEWOOD LN
THE VILLAGES FL
32162-7181
US

V. Phone/Fax

Practice location:
  • Phone: 352-259-0634
  • Fax: 352-259-2174
Mailing address:
  • Phone: 352-259-0634
  • Fax: 352-259-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME80483
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME80483
License Number StateFL

VIII. Authorized Official

Name: DR. WINSTON EVALLE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 352-259-0364