Provider Demographics
NPI:1992817548
Name:VILLAR, MARLA VIONETTE (MD)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:VIONETTE
Last Name:VILLAR
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 1:12171 SW 268TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8001
Mailing Address - Country:US
Mailing Address - Phone:305-278-0200
Mailing Address - Fax:
Practice Address - Street 1:1100 CESERY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5674
Practice Address - Country:US
Practice Address - Phone:904-551-5884
Practice Address - Fax:904-562-3384
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN900208D00000X
PR013678208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH72350Medicare UPIN