Provider Demographics
NPI:1669693933
Name:VILLALBA, BENJAMIN R (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:R
Last Name:VILLALBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 SAN PEDRO AVENUE
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33156
Mailing Address - Country:US
Mailing Address - Phone:305-667-0805
Mailing Address - Fax:305-667-7731
Practice Address - Street 1:14875 NW 77TH AVENUE
Practice Address - Street 2:SUITE #100
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014
Practice Address - Country:US
Practice Address - Phone:305-822-2380
Practice Address - Fax:305-824-0665
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 33974207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069249200Medicaid
FL069249200Medicaid
FL95406Medicare PIN