Provider Demographics
NPI:1639122047
Name:ILAGAN, PETRONIO (MD)
Entity Type:Individual
Prefix:
First Name:PETRONIO
Middle Name:
Last Name:ILAGAN
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 1:1040 SIERRA DR STE 400
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3900 ST FRANCIS WAY STE 200
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4940
Practice Address - Country:US
Practice Address - Phone:765-775-2800
Practice Address - Fax:765-775-2831
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4256882084N0400X
IN01030521A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100250920Medicaid
PA1011908700001Medicaid
IN231420CCOtherMEDICARE