Healthcare Provider Details

I. General information

NPI: 1093784803
Provider Name (Legal Business Name): EDWIN VILLAMATER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 KERNAN DR
BALTIMORE MD
21207-6665
US

IV. Provider business mailing address

PO BOX 132
STEVENSON MD
21153-0132
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-6720
  • Fax:
Mailing address:
  • Phone: 410-321-4535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD42622
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD423862
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: