Provider Demographics
NPI:1447419726
Name:VILCA, RAUL LUIS (MD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:LUIS
Last Name:VILCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9608
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11555-9608
Mailing Address - Country:US
Mailing Address - Phone:718-261-0444
Mailing Address - Fax:718-261-0940
Practice Address - Street 1:12510 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1519
Practice Address - Country:US
Practice Address - Phone:718-261-0444
Practice Address - Fax:718-261-0940
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41816207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100055030Medicaid
NY265821OtherLICENSE NUMBER
KY000000584955OtherBCBS
NY265821OtherLICENSE NUMBER
KY7100055030Medicaid