Provider Demographics
NPI:1801939277
Name:VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC PA
Entity type:Organization
Organization Name:VILLAGES INTERNAL MEDICINE AND SENIOR CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WINSTON
Authorized Official - Middle Name:
Authorized Official - Last Name:EVALLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-259-0364
Mailing Address - Street 1:3351 WEDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-7181
Mailing Address - Country:US
Mailing Address - Phone:352-259-0634
Mailing Address - Fax:352-259-2174
Practice Address - Street 1:3351 WEDGEWOOD LN
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-7181
Practice Address - Country:US
Practice Address - Phone:352-259-0634
Practice Address - Fax:352-259-2174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80483207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL58634OtherBLUE CROSS BLUE SHIELD
FLH21863Medicare UPIN
FLK4849Medicare ID - Type Unspecified