Healthcare Provider Details

I. General information

NPI: 1093234858
Provider Name (Legal Business Name): LIEZL VILLAVERDE, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BYRNE AVE
STATEN ISLAND NY
10314
US

IV. Provider business mailing address

105 BYRNE AVE
STATEN ISLAND NY
10314
US

V. Phone/Fax

Practice location:
  • Phone: 718-698-7220
  • Fax: 718-698-2004
Mailing address:
  • Phone: 718-689-7220
  • Fax: 718-698-2004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number210729
License Number StateNY

VIII. Authorized Official

Name: MRS. LIEZL VILLAVERDE
Title or Position: PRESIDENT
Credential: MD
Phone: 718-698-7220