Provider Demographics
NPI:1093234858
Name:LIEZL VILLAVERDE, MD PC
Entity Type:Organization
Organization Name:LIEZL VILLAVERDE, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LIEZL
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLAVERDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-698-7220
Mailing Address - Street 1:105 BYRNE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:718-689-7220
Mailing Address - Fax:718-698-2004
Practice Address - Street 1:105 BYRNE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-698-7220
Practice Address - Fax:718-698-2004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIEZL VILLAVERDE, MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210729208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty