Healthcare Provider Details

I. General information

NPI: 1760514004
Provider Name (Legal Business Name): JORGE J VILLALBA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12245 BROADWATER LOOP
THONOTOSASSA FL
33592
US

IV. Provider business mailing address

12245 BROADWATER LOOP
THONOTOSASSA FL
33592
US

V. Phone/Fax

Practice location:
  • Phone: 813-708-2728
  • Fax:
Mailing address:
  • Phone: 813-708-2728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME55888
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: