Provider Demographics
NPI:1144310244
Name:VILLALTA, JOSUE J (MD)
Entity type:Individual
Prefix:DR
First Name:JOSUE
Middle Name:J
Last Name:VILLALTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6920 PARKDALE PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5612
Mailing Address - Country:US
Mailing Address - Phone:317-329-7177
Mailing Address - Fax:317-329-7180
Practice Address - Street 1:6920 PARKDALE PL
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5612
Practice Address - Country:US
Practice Address - Phone:317-329-7177
Practice Address - Fax:317-329-7180
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029614A207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000093399OtherBLUE SHIELD
IN000000093399OtherBLUE SHIELD
INB29550Medicare UPIN