1073587895 NPI number — MINERVA VILLAFANE MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073587895 NPI number — MINERVA VILLAFANE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VILLAFANE
Provider First Name:
MINERVA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VILLAFANE-GARCIA
Provider Other First Name:
MINERVA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1073587895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1428 CANDLEWYCKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17057-2900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-320-6269
Provider Business Mailing Address Fax Number:
717-939-2503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PATHWAYS CENTER
Provider Second Line Business Practice Location Address:
122-C GORDON COMMERCIAL DR
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30240-5754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-845-4045
Provider Business Practice Location Address Fax Number:
706-845-4367
Provider Enumeration Date:
02/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  MD439863 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000856413A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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