Provider Demographics
NPI:1609953819
Name:VILLAMOR, MAXIMINO P (RPT)
Entity Type:Individual
Prefix:
First Name:MAXIMINO
Middle Name:P
Last Name:VILLAMOR
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5039 SIESTA DEL RIO DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258
Mailing Address - Country:US
Mailing Address - Phone:904-866-4660
Mailing Address - Fax:904-866-4660
Practice Address - Street 1:4898 DEEDER CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-4209
Practice Address - Country:US
Practice Address - Phone:904-880-6591
Practice Address - Fax:904-880-6591
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist