Provider Demographics
NPI:1972856516
Name:THE VILLAGE PHYSICIAN LLC
Entity Type:Organization
Organization Name:THE VILLAGE PHYSICIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHAHMIRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-206-5688
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34421-0007
Mailing Address - Country:US
Mailing Address - Phone:352-347-7332
Mailing Address - Fax:347-352-4478
Practice Address - Street 1:10435 SE 170TH PL
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8998
Practice Address - Country:US
Practice Address - Phone:352-347-7332
Practice Address - Fax:347-352-4478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0075362207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty