Basic Information
| Provider Information | |||||||||
| NPI: | 1235314436 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VILLAR | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9910 FRANKLIN SQUARE DR STE 2110 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212364902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109335412 | ||||||||
| FaxNumber: | 4109331390 | ||||||||
| Practice Location | |||||||||
| Address1: | 14090 HG TRUEMAN RD | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | SOLOMONS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103943712 | ||||||||
| FaxNumber: | 4103943714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2008 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D0067495 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 415733800 | 05 | MD | MEDICAID |