Provider Demographics
NPI:1437336690
Name:CORAL J VILLANUEVA DPM PA
Entity Type:Organization
Organization Name:CORAL J VILLANUEVA DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORAL
Authorized Official - Middle Name:J
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:786-859-3509
Mailing Address - Street 1:6540 NW 114TH AVE
Mailing Address - Street 2:APT 1403
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4587
Mailing Address - Country:US
Mailing Address - Phone:786-859-3509
Mailing Address - Fax:
Practice Address - Street 1:1090 KANE CONCOURSE
Practice Address - Street 2:SUITE 204
Practice Address - City:BAY HARBOR ISLANDS
Practice Address - State:FL
Practice Address - Zip Code:33154-2130
Practice Address - Country:US
Practice Address - Phone:305-893-9366
Practice Address - Fax:305-893-4408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3285261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric