Provider Demographics
NPI:1073587895
Name:VILLAFANE, MINERVA (MD)
Entity Type:Individual
Prefix:
First Name:MINERVA
Middle Name:
Last Name:VILLAFANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MINERVA
Other - Middle Name:
Other - Last Name:VILLAFANE-GARCIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1428 CANDLEWYCKE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17057-2900
Mailing Address - Country:US
Mailing Address - Phone:478-320-6269
Mailing Address - Fax:717-939-2503
Practice Address - Street 1:PATHWAYS CENTER
Practice Address - Street 2:122-C GORDON COMMERCIAL DR
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5754
Practice Address - Country:US
Practice Address - Phone:706-845-4045
Practice Address - Fax:706-845-4367
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4398632084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000856413AMedicaid
GAH08262Medicare UPIN
GA000856413AMedicaid