Provider Demographics
NPI:1578631636
Name:VILLACIS, LOURDES (DO)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:VILLACIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 WISCONSIN AVE
Mailing Address - Street 2:BUILDING 10, 7TH FLOOR, #7125
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20889
Mailing Address - Country:US
Mailing Address - Phone:301-400-0492
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSING AVE
Practice Address - Street 2:BUILDING 10, # 7125
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889
Practice Address - Country:US
Practice Address - Phone:301-400-0492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH00621962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH0062196Medicaid