Provider Demographics
NPI:1629092564
Name:VILLA, MARIVIC DELOS REYES (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIVIC
Middle Name:DELOS REYES
Last Name:VILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1507 BUENOS AIRES BLVD
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8974
Mailing Address - Country:US
Mailing Address - Phone:352-561-6299
Mailing Address - Fax:352-750-8032
Practice Address - Street 1:10250 SE 167TH PLACE RD
Practice Address - Street 2:SUITE 5
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8686
Practice Address - Country:US
Practice Address - Phone:352-307-9925
Practice Address - Fax:352-307-8442
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68756207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378148800Medicaid
FLF30701Medicare UPIN
FL378148800Medicaid
FL27450XMedicare PIN