Basic Information
| Provider Information | |||||||||
| NPI: | 1417938705 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VILLAMIL | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 TOTTEN POND RD | ||||||||
| Address2: | C O MZI | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818909933 | ||||||||
| FaxNumber: | 7818909950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CRANBERRY HL STE 303 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024217397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812900057 | ||||||||
| FaxNumber: | 7812900059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 07/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | 152633 | MA | Y | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | 152633 | MA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | J21067 | 01 | MA | BCBS | OTHER |