Provider Demographics
NPI:1487621694
Name:MEDICAL VILLAGE HEALTHCARE GROUP
Entity type:Organization
Organization Name:MEDICAL VILLAGE HEALTHCARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:
Authorized Official - Last Name:MANZUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-944-9777
Mailing Address - Street 1:1462 W OAK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-3905
Mailing Address - Country:US
Mailing Address - Phone:407-944-9777
Mailing Address - Fax:407-944-9796
Practice Address - Street 1:201 HILDA ST
Practice Address - Street 2:SECOND FLOOR SUITE 21
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2320
Practice Address - Country:US
Practice Address - Phone:407-944-9777
Practice Address - Fax:407-888-3310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA61366OtherINDIVIDUAL PROVIDER UPIN
FL62935ZOtherINDIVIDUAL PROVIDER PTAN
FLAC082ZOtherINDIVIDUAL PROVIDER PTAN
FLG14896OtherINDIVIDUAL PROVIDER UPIN
FLA61366OtherINDIVIDUAL PROVIDER UPIN