Provider Demographics
NPI:1598720476
Name:VILLARRUEL, LUIS L (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:L
Last Name:VILLARRUEL
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 1:10614 TENNISON DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-8392
Mailing Address - Country:US
Mailing Address - Phone:317-826-0962
Mailing Address - Fax:317-826-0962
Practice Address - Street 1:9301 E 59TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-2236
Practice Address - Country:US
Practice Address - Phone:317-964-7064
Practice Address - Fax:317-964-7087
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030281A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4392375OtherAETNA PIN#
IN200311740Medicaid
IN100325900Medicaid
IN000000475865OtherANTHEM PIN#
IN4392375OtherAETNA PIN#
INF07036Medicare UPIN