Provider Demographics
NPI:1598718579
Name:VILLASIS, CYNTHIA D (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:D
Last Name:VILLASIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E PENN SQ
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9232
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:65 W JIMMIE LEEDS RD
Practice Address - Street 2:CHOP CARE NETWORK @ ATLANTICARE
Practice Address - City:POMONA
Practice Address - State:NJ
Practice Address - Zip Code:08240-9102
Practice Address - Country:US
Practice Address - Phone:609-404-3816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036907L208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2253288OtherCIGNA HMO/PPO
PA0007930170010Medicaid
PA10938189OtherCAQH ID#
PA417451OtherHIGHMARK BLUE SHIELD
PA417451OtherHIGHMARK BLUE SHIELD