Provider Demographics
NPI:1528018710
Name:VILLEGAS, MARIO C (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:C
Last Name:VILLEGAS
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 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4304
Practice Address - Street 1:601 STATE ROUTE 664 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-8541
Practice Address - Country:US
Practice Address - Phone:710-380-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050563V207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0575426Medicaid
000000342030OtherBCBS MADISON
000000315936OtherBCBS
000000342030OtherBCBS MADISON
OHP00139010Medicare PIN
VI0734667Medicare PIN
F28911Medicare UPIN
OH0575426Medicaid