Provider Demographics
NPI:1780247866
Name:VILLAVER, DEODITO SELLOTE (RPT)
Entity type:Individual
Prefix:MR
First Name:DEODITO
Middle Name:SELLOTE
Last Name:VILLAVER
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:MR
Other - First Name:DEODITO
Other - Middle Name:SELLOTE
Other - Last Name:VILLAVER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPT
Mailing Address - Street 1:11 ALIX RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-7012
Mailing Address - Country:US
Mailing Address - Phone:814-886-3265
Mailing Address - Fax:845-787-5323
Practice Address - Street 1:11 ALIX RD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-7012
Practice Address - Country:US
Practice Address - Phone:814-886-3265
Practice Address - Fax:845-787-5323
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017079-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist