Provider Demographics
NPI:1053660001
Name:VILLADA, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:VILLADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11347 GRANDVILLE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2387
Mailing Address - Country:US
Mailing Address - Phone:813-400-4880
Mailing Address - Fax:813-490-5495
Practice Address - Street 1:11347 GRANDVILLE DR
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-2387
Practice Address - Country:US
Practice Address - Phone:813-400-4880
Practice Address - Fax:813-490-5495
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator