Provider Demographics
NPI:1811041155
Name:VILLA FUERTE, CEFERINO REYES JR (MD)
Entity Type:Individual
Prefix:
First Name:CEFERINO
Middle Name:REYES
Last Name:VILLA FUERTE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CEFERINO
Other - Middle Name:R
Other - Last Name:VILLA FUERTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MDP
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:133 EAST MAIN ST
Mailing Address - City:CAMBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12816
Mailing Address - Country:US
Mailing Address - Phone:518-677-5723
Mailing Address - Fax:518-677-5723
Practice Address - Street 1:200 SMITH DRIVE
Practice Address - Street 2:ADIRONDACK CLINIC
Practice Address - City:CORINTH
Practice Address - State:NY
Practice Address - Zip Code:12822
Practice Address - Country:US
Practice Address - Phone:518-654-7680
Practice Address - Fax:518-654-7693
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY105492208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00358310Medicaid
CV33794BMedicare ID - Type Unspecified
D02013Medicare UPIN