Healthcare Provider Details

I. General information

NPI: 1730496100
Provider Name (Legal Business Name): OLMEDO ELOY VILLAVICENCIO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S CARLIN SPRINGS RD
ARLINGTON VA
22204-1044
US

IV. Provider business mailing address

601 S CARLIN SPRINGS RD
ARLINGTON VA
22204-1050
US

V. Phone/Fax

Practice location:
  • Phone: 703-271-8800
  • Fax: 703-271-8585
Mailing address:
  • Phone: 703-271-8800
  • Fax: 703-271-8585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101018401
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: