Provider Demographics
NPI:1992042766
Name:VILLELLA, JORGE OCTAVIO III
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:OCTAVIO
Last Name:VILLELLA
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TRESCOTT PATH
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2535
Mailing Address - Country:US
Mailing Address - Phone:631-292-2404
Mailing Address - Fax:
Practice Address - Street 1:1 TRESCOTT PATH
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2535
Practice Address - Country:US
Practice Address - Phone:631-292-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-13
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121894101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY23F602Medicare UPIN
NY008680Medicare UPIN