Provider Demographics
NPI:1225256076
Name:VILLANUEVA, IAN A (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:A
Last Name:VILLANUEVA
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 1:2920 HIGHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-0010
Mailing Address - Country:US
Mailing Address - Phone:877-498-4490
Mailing Address - Fax:
Practice Address - Street 1:208 ASHVILLE AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6678
Practice Address - Country:US
Practice Address - Phone:919-350-9625
Practice Address - Fax:919-851-6757
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-33427208600000X
NC2007-00579208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0057HOtherMEDICAID
NC1225256076Medicaid
KS200585090AMedicaid
NC5907030Medicaid
SCN0057HMedicaid
KS107539OtherBLUE CROSS OF KANSAS
NC145WEOtherNCBCBS
NC1225256076Medicaid
NC5907030Medicaid
SCN0057HOtherMEDICAID
NCNC3636BMedicare PIN