Provider Demographics
NPI:1134507486
Name:VILLEGAS, LUIS
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:VILLEGAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 E CALIFORNIA BLVD APT 218
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-3790
Mailing Address - Country:US
Mailing Address - Phone:917-434-5312
Mailing Address - Fax:917-900-1850
Practice Address - Street 1:800 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3420
Practice Address - Country:US
Practice Address - Phone:951-737-4343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA160813207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine