Healthcare Provider Details

I. General information

NPI: 1194055871
Provider Name (Legal Business Name): VILMA FONDEVILLA TADALAN-VELASCO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2010
Last Update Date: 01/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 KIRKS MILL LN
NORTH EAST MD
21901-1712
US

IV. Provider business mailing address

80 KIRKS MILL LN
NORTH EAST MD
21901-1712
US

V. Phone/Fax

Practice location:
  • Phone: 702-430-8881
  • Fax:
Mailing address:
  • Phone: 702-430-8881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0014635
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: