Healthcare Provider Details

I. General information

NPI: 1063864346
Provider Name (Legal Business Name): MIGUEL MANTILLA-VILLAMIZAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 PINELLAS PL
THE VILLAGES FL
32163-2703
US

IV. Provider business mailing address

1020 LAKE SUMTER LNDG
THE VILLAGES FL
32162-2699
US

V. Phone/Fax

Practice location:
  • Phone: 844-884-9355
  • Fax: 352-674-8920
Mailing address:
  • Phone: 352-674-8905
  • Fax: 352-674-8901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number62653
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME170596
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: