Healthcare Provider Details

I. General information

NPI: 1457403784
Provider Name (Legal Business Name): CARLITO VILLABONA ORIG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 N 65TH ST
CHICAGO IL
60638
US

IV. Provider business mailing address

3900 YORK ROAD
OAK BROOK IL
60523
US

V. Phone/Fax

Practice location:
  • Phone: 708-496-1515
  • Fax: 708-496-1788
Mailing address:
  • Phone: 708-496-1515
  • Fax: 708-496-1788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberMD12875
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: