Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VG0400X | Gynecologist | 01029614A | IN |
NPI | 1144310244 |
---|---|
Provider Name | Dr. Josue J Villalta |
First Address | Indianapolis, IN 46254-5612 |
Second Address | Indianapolis, IN 46254-5612 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000093399 | BLUE SHIELD (01) | IN |
B29550 | (02) | IN |