Basic Information
Provider Information | |||||||||
NPI: | 1508934555 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VILLEGAS | ||||||||
FirstName: | LEONARDO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4205 BELFORT RD STE 4015 | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322163623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9044506014 | ||||||||
FaxNumber: | 9044506401 | ||||||||
Practice Location | |||||||||
Address1: | 730 BAYFRONT PKWY STE 5A | ||||||||
Address2: |   | ||||||||
City: | PENSACOLA | ||||||||
State: | FL | ||||||||
PostalCode: | 325026250 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8504325488 | ||||||||
FaxNumber: | 8504325228 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2006 | ||||||||
LastUpdateDate: | 02/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2009-01041 | NC | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2086X0206X | ME110757 | FL | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
ID | Type | State | Issuer | Description | 14FC8 | 01 | FL | BCBSFL | OTHER | 592-21627 | 01 | AL | BCBS | OTHER | 003997200 | 05 | FL |   | MEDICAID |