=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629092564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIVIC DELOS REYES VILLA M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 04/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10250 SE 167TH PLACE RD SUITE 5
-----------------------------------------------------
City | SUMMERFIELD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34491-8686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-307-9925
-----------------------------------------------------
Fax | 352-307-8442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1507 BUENOS AIRES BLVD
-----------------------------------------------------
City | THE VILLAGES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159-8974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-561-6299
-----------------------------------------------------
Fax | 352-750-8032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME68756
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RP1001X
-----------------------------------------------------
Taxonomy Name | Pulmonary Disease Physician
-----------------------------------------------------
License Number | ME68756
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------