Provider Demographics
NPI:1942344296
Name:VILLAGE DOCTORS PA
Entity Type:Organization
Organization Name:VILLAGE DOCTORS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SIKES
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:904-964-5455
Mailing Address - Street 1:100 S LAWRENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-9215
Mailing Address - Country:US
Mailing Address - Phone:352-473-9373
Mailing Address - Fax:352-473-0037
Practice Address - Street 1:100 S LAWRENCE BLVD
Practice Address - Street 2:
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-9215
Practice Address - Country:US
Practice Address - Phone:352-473-9373
Practice Address - Fax:352-473-0037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
K6724Medicare ID - Type Unspecified