Provider Demographics
NPI:1932278181
Name:VILLALTA-WEHMEYER, IVAN A (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:A
Last Name:VILLALTA-WEHMEYER
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 1:39359 BAY DR
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-6657
Mailing Address - Country:US
Mailing Address - Phone:985-230-6900
Mailing Address - Fax:985-230-6531
Practice Address - Street 1:15790 PAUL VEGA MD, DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403
Practice Address - Country:US
Practice Address - Phone:985-230-6900
Practice Address - Fax:985-230-6531
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032685A2080N0001X
LAMD06771R2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1392995Medicaid