Provider Demographics
NPI:1235265042
Name:VILLA, LUIS C (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:C
Last Name:VILLA
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 1:1140 W LA VETA AVE
Mailing Address - Street 2:700
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:700
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4223
Practice Address - Country:US
Practice Address - Phone:714-547-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG07952Medicare UPIN