Provider Demographics
NPI:1841386075
Name:VILLAVERDE, LIEZL R (MD)
Entity Type:Individual
Prefix:
First Name:LIEZL
Middle Name:R
Last Name:VILLAVERDE
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 1:105 BYRNE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4406
Mailing Address - Country:US
Mailing Address - Phone:718-698-7220
Mailing Address - Fax:718-698-2004
Practice Address - Street 1:105 BYRNE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4406
Practice Address - Country:US
Practice Address - Phone:718-698-7220
Practice Address - Fax:718-698-2004
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210729208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
551231Medicare ID - Type Unspecified
G80431Medicare UPIN