Provider Demographics
NPI:1063463339
Name:VILLEGAS, SERGIO BANUELOS (MD)
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:BANUELOS
Last Name:VILLEGAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5823 YORK BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-2634
Mailing Address - Country:US
Mailing Address - Phone:323-255-5643
Mailing Address - Fax:323-254-2158
Practice Address - Street 1:1701 E CESAR CHAVEZ AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2464
Practice Address - Country:US
Practice Address - Phone:323-317-9200
Practice Address - Fax:323-317-9206
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G653630OtherBLUE SHIELD
GA080052215OtherMEDICARE RAILROAD
CA00G653630Medicaid
CAE82771Medicare UPIN
CAWG65363CMedicare PIN