Healthcare Provider Details

I. General information

NPI: 1508804659
Provider Name (Legal Business Name): DAVID R VILLASANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 CANTON RD NE SUITE 210
MARIETTA GA
30060-8948
US

IV. Provider business mailing address

711 CANTON RD NE SUITE 210
MARIETTA GA
30060-8948
US

V. Phone/Fax

Practice location:
  • Phone: 770-426-3977
  • Fax: 770-421-8567
Mailing address:
  • Phone: 770-426-3977
  • Fax: 770-421-8567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number034973
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number034973
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: