Healthcare Provider Details

I. General information

NPI: 1528139771
Provider Name (Legal Business Name): JOSE D VILLAGRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 UNIVERSITY BLVD W STE 410
WHEATON MD
20902-1972
US

IV. Provider business mailing address

2730 UNIVERSITY BLVD W STE 410
WHEATON MD
20902-1972
US

V. Phone/Fax

Practice location:
  • Phone: 240-669-6330
  • Fax: 240-669-6757
Mailing address:
  • Phone: 240-669-6330
  • Fax: 240-669-6757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0059258
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: