Provider Demographics
NPI:1447936463
Name:VILLA, IAN
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:VILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SHENANDOAH VIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:MD
Mailing Address - Zip Code:21716-9780
Mailing Address - Country:US
Mailing Address - Phone:714-270-7666
Mailing Address - Fax:
Practice Address - Street 1:1200 SHENANDOAH VIEW PKWY
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:MD
Practice Address - Zip Code:21716-9780
Practice Address - Country:US
Practice Address - Phone:714-270-7666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27776225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist