Provider Demographics
NPI:1639136104
Name:VILLAR, VANESSA (MD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:VILLAR
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:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21922-0190
Mailing Address - Country:US
Mailing Address - Phone:410-398-4679
Mailing Address - Fax:410-620-3686
Practice Address - Street 1:361 FAIR HILL DR
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-2512
Practice Address - Country:US
Practice Address - Phone:410-620-7260
Practice Address - Fax:410-620-7262
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD003469207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00275555OtherMEDICARE RAILROAD
MD199NMedicare ID - Type Unspecified
P00275555OtherMEDICARE RAILROAD