Provider Demographics
NPI:1508969155
Name:VILLA, DOUGLAS LEWIS (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:LEWIS
Last Name:VILLA
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 1:212 EAST B ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801
Mailing Address - Country:US
Mailing Address - Phone:906-774-2990
Mailing Address - Fax:906-774-5950
Practice Address - Street 1:212 E B ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3411
Practice Address - Country:US
Practice Address - Phone:906-774-2990
Practice Address - Fax:906-774-5950
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30637100Medicaid
080007579OtherRAILROAD MEDICARE
MI1631523Medicaid
WI000101Medicare Oscar/Certification
WI000011Medicare Oscar/Certification
MIOP383400006Medicare PIN
MI1631523Medicaid
080007579OtherRAILROAD MEDICARE
WI000025Medicare Oscar/Certification
B44087Medicare UPIN
WI30637100Medicaid
WIP00046864Medicare Oscar/Certification
MI0220026Medicare ID - Type Unspecified
MIOP383400006Medicare Oscar/Certification
WI000030Medicare Oscar/Certification
WI000032Medicare Oscar/Certification
WI000023Medicare Oscar/Certification