Provider Demographics
NPI:1730496100
Name:VILLAVICENCIO, OLMEDO ELOY (MD)
Entity Type:Individual
Prefix:
First Name:OLMEDO
Middle Name:ELOY
Last Name:VILLAVICENCIO
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 1:601 S CARLIN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-1050
Mailing Address - Country:US
Mailing Address - Phone:703-271-8800
Mailing Address - Fax:703-271-8585
Practice Address - Street 1:601 S CARLIN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-1044
Practice Address - Country:US
Practice Address - Phone:703-271-8800
Practice Address - Fax:703-271-8585
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101018401208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics