Basic Information
| Provider Information | |||||||||
| NPI: | 1922331735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLALONGA | ||||||||
| FirstName: | HAISEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 SW 69TH AVE | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333175026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862854463 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6233 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | TAMARAC | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333214022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547210000 | ||||||||
| FaxNumber: | 9547216308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2009 | ||||||||
| LastUpdateDate: | 05/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC4441 | FL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPC 4441 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 001230400 | 05 | FL | MEDICAID | 8740 | 01 | FL | ICARE | OTHER |