Provider Demographics
NPI:1437251899
Name:VILLOCH, CHARLES ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANTHONY
Last Name:VILLOCH
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:PO BOX 451205
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33245-1205
Mailing Address - Country:US
Mailing Address - Phone:305-858-2211
Mailing Address - Fax:305-856-5252
Practice Address - Street 1:2075 SW 27 AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145
Practice Address - Country:US
Practice Address - Phone:305-858-2211
Practice Address - Fax:305-856-5252
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0055644207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061694000Medicaid
FL061694000Medicaid
E75820Medicare UPIN