Provider Demographics
NPI:1861630626
Name:MEDICAL VILLAGE HEALTHCARE GROUP
Entity Type:Organization
Organization Name:MEDICAL VILLAGE HEALTHCARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:
Authorized Official - Last Name:MANZUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-888-6990
Mailing Address - Street 1:816 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-6625
Mailing Address - Country:US
Mailing Address - Phone:407-944-9777
Mailing Address - Fax:
Practice Address - Street 1:1462 W OAK RIDGE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-3905
Practice Address - Country:US
Practice Address - Phone:407-888-6990
Practice Address - Fax:407-888-3310
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL VILLAGE HEALTHCARE GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-31
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81287207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1376516575OtherINDIVIDUAL PROVIDER NPI
FL1447223193OtherINDIVIDUAL PROVIDER NPI
FLG14896Medicare UPIN
FLA61366Medicare UPIN