Provider Demographics
NPI:1326073248
Name:VILLELLA, DOUGLAS J (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
Last Name:VILLELLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 STATE ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1427
Mailing Address - Country:US
Mailing Address - Phone:814-454-6517
Mailing Address - Fax:814-454-0604
Practice Address - Street 1:300 STATE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1427
Practice Address - Country:US
Practice Address - Phone:814-454-6517
Practice Address - Fax:814-454-0604
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001102152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0727940001OtherDMERC A
PADG8866OtherR.R. MEDICARE
PA535215Medicare PIN
PA473949JDGMedicare PIN
PA0727940001OtherDMERC A
PAT30634Medicare UPIN
PADG8866OtherR.R. MEDICARE
PADG8866Medicare PIN
PA0727940001Medicare PIN