Provider Demographics
NPI:1447217625
Name:VILLASUSO, RAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:
Last Name:VILLASUSO
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 1:675 W NORTH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1634
Mailing Address - Country:US
Mailing Address - Phone:708-450-4994
Mailing Address - Fax:708-344-0877
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-450-4994
Practice Address - Fax:708-344-0877
Is Sole Proprietor?:No
Enumeration Date:2006-04-30
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-046657208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL53519Medicare UPIN
ILC41698Medicare PIN