MEDICARE: JOHN BERNARD VILLEGAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	049718	NY

General Provider Information

NPI Number	:	1043928799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN BERNARD VILLEGAS

Provider Business Mailing Address
First Line	:	4258 79TH ST
Second Line	:
City	:	ELMHURST
State	:	NY
Zip	:	11373-3057
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4011 WARREN ST BSMT
Second Line	:
City	:	ELMHURST
State	:	NY
Zip	:	11373-1700
Country	:	US
Telephone Number	:	929-429-2300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2022
Last Update Date	:	11/14/2022

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