Healthcare Provider Details

I. General information

NPI: 1447418397
Provider Name (Legal Business Name): EDWIN ENRIQUE VILLARREAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EDWIN VILLARREAL MAZZILLI MD

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 HISTORIC HWY 441-N
DEMOREST GA
30535-4528
US

IV. Provider business mailing address

PO BOX 658
GAINESVILLE GA
30503-0658
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-7078
  • Fax: 770-219-7365
Mailing address:
  • Phone: 770-718-1122
  • Fax: 770-535-7445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number63221
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number066663
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number066663
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: