Provider Demographics
NPI:1487741377
Name:WESTSIDE GYNECOLOGY, INC.
Entity type:Organization
Organization Name:WESTSIDE GYNECOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSUE
Authorized Official - Middle Name:J
Authorized Official - Last Name:VILLALTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-329-7177
Mailing Address - Street 1:6920 PARKDALE PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5612
Mailing Address - Country:US
Mailing Address - Phone:317-329-7177
Mailing Address - Fax:317-329-7180
Practice Address - Street 1:6920 PARKDALE PL
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5612
Practice Address - Country:US
Practice Address - Phone:317-329-7177
Practice Address - Fax:317-329-7180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029614A207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000093399OtherBLUE SHIELD NUMBER
INB29550Medicare UPIN
IN137740Medicare ID - Type UnspecifiedMEDICARE NUMBER