Provider Demographics
NPI:1841384948
Name:ANDRES R VILLAR MD
Entity Type:Organization
Organization Name:ANDRES R VILLAR MD
Other - Org Name:CHILDREN'S MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:R
Authorized Official - Last Name:VILLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-755-5044
Mailing Address - Street 1:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:GLEN ST MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32040-0606
Mailing Address - Country:US
Mailing Address - Phone:904-653-1818
Mailing Address - Fax:904-653-1814
Practice Address - Street 1:1419 S 6TH ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-4624
Practice Address - Country:US
Practice Address - Phone:904-653-1822
Practice Address - Fax:904-259-1225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 261QR1300X
FLME52004103TC0700X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370861605Medicaid
FL370861608Medicaid