Healthcare Provider Details

I. General information

NPI: 1487741377
Provider Name (Legal Business Name): WESTSIDE GYNECOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/22/2020
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: DR. JOSUE J VILLALTA
Title or Position: PRESIDENT
Credential: MD
Phone: 317-329-7177