1467050120 NPI number — EDWIN FRANCOIS XAVIER VILLERT PA

Table of content: EDWIN FRANCOIS XAVIER VILLERT PA (NPI 1467050120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467050120 NPI number — EDWIN FRANCOIS XAVIER VILLERT PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VILLERT
Provider First Name:
EDWIN
Provider Middle Name:
FRANCOIS XAVIER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1467050120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1028 SLATER RD APT 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27703-8468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-844-1594
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MATRIX OCCUPATIONAL HEALTH PC
Provider Second Line Business Practice Location Address:
1110 KILDAIRE FARM ROAD
Provider Business Practice Location Address City Name:
CARY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-481-0277
Provider Business Practice Location Address Fax Number:
919-481-9777
Provider Enumeration Date:
10/15/2020

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: 363A00000X , with the licence number:  PA9113585 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0010-12221 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 108470000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com