Provider Demographics
NPI:1194827097
Name:VILLACASTIN, ALEX TAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:TAN
Last Name:VILLACASTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10489 N FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:CITRUS SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34434-3268
Mailing Address - Country:US
Mailing Address - Phone:352-489-2486
Mailing Address - Fax:352-489-5786
Practice Address - Street 1:10489 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:CITRUS SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34434-3268
Practice Address - Country:US
Practice Address - Phone:352-489-2486
Practice Address - Fax:352-489-5786
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME071085207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
32745OtherBLUE CROSS BLUE SHIELD
593411454OtherHUMANA
225194OtherAVMED
FL25180660Medicaid
FL103957Medicare ID - Type Unspecified
FL25180660Medicaid