Basic Information
Provider Information
NPI: 1003804485
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VILLEGAS
FirstName: AUGUSTO
MiddleName: E
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4371 VERONICA S SHOEMAKER BLVD
Address2: ATTN: CREDENTIALING
City: FORT MYERS
State: FL
PostalCode: 339162216
CountryCode: US
TelephoneNumber: (239) 274-8200
FaxNumber: 8139767895
Practice Location
Address1: 4689 US HIGHWAY 17 STE 2-5
Address2:  
City: FLEMING ISLAND
State: FL
PostalCode: 320034831
CountryCode: US
TelephoneNumber: 9042696526
FaxNumber: 9042696527
Other Information
ProviderEnumerationDate: 10/11/2005
LastUpdateDate: 11/21/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RX0202XME88469FLY Allopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology

ID Information
IDTypeStateIssuerDescription
440667962H05GA MEDICAID
27468590005FL MEDICAID
701382801FLAETNAOTHER
1616801FLBC BSOTHER


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