Provider Demographics
NPI:1235272949
Name:VILLAMIZAR, IVAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:E
Last Name:VILLAMIZAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 LOTHIAN RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-4003
Mailing Address - Country:US
Mailing Address - Phone:754-244-8266
Mailing Address - Fax:
Practice Address - Street 1:2401 W BELVEDERE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5216
Practice Address - Country:US
Practice Address - Phone:410-601-5284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP21293208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics