Provider Demographics
NPI:1124216601
Name:EDWIN M VILLALOBOS MD PA
Entity Type:Organization
Organization Name:EDWIN M VILLALOBOS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:VILLALOBOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-331-0771
Mailing Address - Street 1:661 E ALTAMONTE DR
Mailing Address - Street 2:SUITE 231
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5105
Mailing Address - Country:US
Mailing Address - Phone:407-331-0771
Mailing Address - Fax:407-331-0577
Practice Address - Street 1:661 E ALTAMONTE DR
Practice Address - Street 2:SUITE 231
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5105
Practice Address - Country:US
Practice Address - Phone:407-331-0771
Practice Address - Fax:407-331-0577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME443322081P2900X
FLPA9101382363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8618Medicare PIN