1104986892 NPI number — KATHRYN SLOTT VILLANO MD

Table of content: KATHRYN SLOTT VILLANO MD (NPI 1104986892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104986892 NPI number — KATHRYN SLOTT VILLANO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VILLANO
Provider First Name:
KATHRYN
Provider Middle Name:
SLOTT
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:
SLOTT
Provider Other First Name:
KATHRYN
Provider Other Middle Name:
STANLEY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104986892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 CONCORD TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33323-2815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-243-3839
Provider Business Mailing Address Fax Number:
855-527-5510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
836 PRUDENTIAL DR
Provider Second Line Business Practice Location Address:
SUITE #1800
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-8334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-398-7684
Provider Business Practice Location Address Fax Number:
904-398-4998
Provider Enumeration Date:
12/11/2006

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: 207VM0101X , with the licence number:  ME 95466 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001479500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 104580200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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