Provider Demographics
NPI:1780643627
Name:VILLAVICENCIO, RAPHAEL (MD)
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:VILLAVICENCIO
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 1:1481 W 10TH ST
Mailing Address - Street 2:MEDICINE SERVICE, 111
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2803
Mailing Address - Country:US
Mailing Address - Phone:317-554-0000
Mailing Address - Fax:
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:MEDICINE SERVICE, 111
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-554-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051969A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200300450Medicaid
IN9397565OtherPHCS PID NUMBER
IN000000351160OtherANTHEM PROVIDER NUMBER
IN815500G8Medicare PIN
INP00162690Medicare PIN
INH24565Medicare UPIN
IN200300450Medicaid