Provider Demographics
NPI:1972513331
Name:VILLANUEVA, LISA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S WASHINGTON AVE
Mailing Address - Street 2:SUITE 122
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4200
Mailing Address - Country:US
Mailing Address - Phone:847-692-6628
Mailing Address - Fax:847-692-6891
Practice Address - Street 1:101 S WASHINGTON AVE
Practice Address - Street 2:SUITE 122
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4200
Practice Address - Country:US
Practice Address - Phone:847-692-6628
Practice Address - Fax:847-692-6891
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-093553208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093553Medicaid