Provider Demographics
NPI:1194055871
Name:TADALAN-VELASCO, VILMA FONDEVILLA (MD)
Entity type:Individual
Prefix:
First Name:VILMA
Middle Name:FONDEVILLA
Last Name:TADALAN-VELASCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 KIRKS MILL LN
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-1712
Mailing Address - Country:US
Mailing Address - Phone:702-430-8881
Mailing Address - Fax:
Practice Address - Street 1:80 KIRKS MILL LN
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-1712
Practice Address - Country:US
Practice Address - Phone:702-430-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-03
Last Update Date:2010-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0014635208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics