Healthcare Provider Details

I. General information

NPI: 1144310244
Provider Name (Legal Business Name): JOSUE J VILLALTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6920 PARKDALE PL SUITE 100
INDIANAPOLIS IN
46254-5612
US

IV. Provider business mailing address

6920 PARKDALE PL SUITE 100
INDIANAPOLIS IN
46254-5612
US

V. Phone/Fax

Practice location:
  • Phone: 317-329-7177
  • Fax: 317-329-7180
Mailing address:
  • Phone: 317-329-7177
  • Fax: 317-329-7180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number01029614A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: