Provider Demographics
NPI:1821122656
Name:VILLA PASTOR, IDA LUZ (MD)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:LUZ
Last Name:VILLA PASTOR
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:VILLAS DE PLAYA I
Mailing Address - Street 2:URB DORADO DEL MAR APT N 1
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646
Mailing Address - Country:US
Mailing Address - Phone:787-796-4523
Mailing Address - Fax:
Practice Address - Street 1:MENDEZ VIGO 410
Practice Address - Street 2:SUITE 204
Practice Address - City:DORADO
Practice Address - State:PR
Practice Address - Zip Code:00646
Practice Address - Country:US
Practice Address - Phone:787-796-1464
Practice Address - Fax:787-278-3338
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9748207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
81968Medicare ID - Type Unspecified
F76346Medicare UPIN