Provider Demographics
NPI:1386939510
Name:VILLACIS, FABIAN CESAR (OD)
Entity type:Individual
Prefix:DR
First Name:FABIAN
Middle Name:CESAR
Last Name:VILLACIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3129
Mailing Address - Country:US
Mailing Address - Phone:203-755-4941
Mailing Address - Fax:203-573-8372
Practice Address - Street 1:1320 W MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3129
Practice Address - Country:US
Practice Address - Phone:203-755-4941
Practice Address - Fax:203-573-8372
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002832152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004195063 GR#Medicaid
CT8043102Medicaid
CTD400084440Medicare PIN