Provider Demographics
NPI:1639435209
Name:VILLA, EDWARD CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:CHARLES
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 1:235 W VAN BUREN ST
Mailing Address - Street 2:UNIT 2108
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3918
Mailing Address - Country:US
Mailing Address - Phone:847-668-3875
Mailing Address - Fax:
Practice Address - Street 1:840 S WOOD ST
Practice Address - Street 2:SUITE 718E CSB, MC 716
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-996-6652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-07
Last Update Date:2019-06-27
Deactivation Date:2018-07-02
Deactivation Code:
Reactivation Date:2018-10-04
Provider Licenses
StateLicense IDTaxonomies
IL036.137394207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine