Provider Demographics
NPI:1154469609
Name:LYDIA S Q VILLAFUERTE MD
Entity Type:Organization
Organization Name:LYDIA S Q VILLAFUERTE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLAFUERTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-854-6262
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-0265
Mailing Address - Country:US
Mailing Address - Phone:217-854-6262
Mailing Address - Fax:217-854-6264
Practice Address - Street 1:205 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1921
Practice Address - Country:US
Practice Address - Phone:217-854-6262
Practice Address - Fax:217-854-6264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211083Medicare ID - Type Unspecified