1811995434 NPI number — JACY VILLA M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811995434 NPI number — JACY VILLA M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

VILLA

Provider First Name:

JACY

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1811995434

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

08/09/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

2234 COLONIAL BLVD

Provider Second Line Business Mailing Address:

ATTN: PAYER CONTRACTING & RELATIONS DEPT.

Provider Business Mailing Address City Name:

FORT MYERS

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

33907-1412

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

239-931-7342

Provider Business Mailing Address Fax Number:

239-931-7385

Provider First Line Business Practice Location Address:

2623 S SEACREST BLVD

Provider Second Line Business Practice Location Address:

SUITE 216

Provider Business Practice Location Address City Name:

BOYNTON BEACH

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

33435-7501

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

561-742-0065

Provider Business Practice Location Address Fax Number:

561-742-0105

Provider Enumeration Date:

07/08/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RX0202X , with the licence number:  24551 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RX0202X , with the licence number: ME80441 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RH0003X , with the licence number: ME80441 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: P1035622 . This is a "FREEDOM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 279218 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 14392 . This is a "DIMENSION" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P01594402 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 5753526 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 8490121 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P971389 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 57987 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 006955000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".