Provider Demographics
NPI:1134374226
Name:AVILLA, CARLOS VILLAVERDE (MSPT)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:VILLAVERDE
Last Name:AVILLA
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CAMDEN CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1583
Mailing Address - Country:US
Mailing Address - Phone:631-736-4334
Mailing Address - Fax:631-736-4333
Practice Address - Street 1:5 CAMDEN CT
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1583
Practice Address - Country:US
Practice Address - Phone:631-736-4334
Practice Address - Fax:631-736-4333
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023135-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics