Provider Demographics
NPI:1659545192
Name:FERNANDO MENDEZ VILLAMIL MD PA
Entity Type:Organization
Organization Name:FERNANDO MENDEZ VILLAMIL MD PA
Other - Org Name:FERNANDO MENDEZ VILLAMIL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDEZ VILLAMIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-860-8484
Mailing Address - Street 1:1898 SW 22ND STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-2731
Mailing Address - Country:US
Mailing Address - Phone:305-860-8484
Mailing Address - Fax:305-860-2084
Practice Address - Street 1:1898 SW 22ND STREET
Practice Address - Street 2:SUITE B
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2731
Practice Address - Country:US
Practice Address - Phone:305-860-8484
Practice Address - Fax:305-860-2084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00756852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL600012584OtherMAGELLAN HEALTH SERVICES
FL255161600Medicaid
FL600012584OtherMAGELLAN HEALTH SERVICES
FLG83410Medicare UPIN