Provider Demographics
NPI:1992289276
Name:VILLAFANA, MARTHA (MA)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:VILLAFANA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6106
Mailing Address - Country:US
Mailing Address - Phone:309-779-2030
Mailing Address - Fax:
Practice Address - Street 1:4600 3RD ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6106
Practice Address - Country:US
Practice Address - Phone:309-779-2032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2084P0800X2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1234OtherIOWA MEDICAID