Provider Demographics
NPI:1851682801
Name:VILLACIS BERMEO, BOLIVAR A (MD)
Entity Type:Individual
Prefix:DR
First Name:BOLIVAR
Middle Name:A
Last Name:VILLACIS BERMEO
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:PADRE SOLANO 1311 Y GARCIA MORENO
Mailing Address - Street 2:EDIFICIO ANVIED, PRIMER PISO, OFICINAS 1 Y 2
Mailing Address - City:GUAYAQUIL
Mailing Address - State:GUAYAS
Mailing Address - Zip Code:090514
Mailing Address - Country:EC
Mailing Address - Phone:5934-229-0931
Mailing Address - Fax:
Practice Address - Street 1:PADRE SOLANO 1311 Y GARCIA MORENO
Practice Address - Street 2:EDIFICIO ANVIED, PRIMER PISO, OFICINAS 1 Y 2
Practice Address - City:GUAYAQUIL
Practice Address - State:GUAYAS
Practice Address - Zip Code:090514
Practice Address - Country:EC
Practice Address - Phone:5934-229-0931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ5625208600000X
MA390200000X
CT390200000X
FL390200000X
ZZ2499390200000X
ZZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program