Provider Demographics
NPI:1124064001
Name:VILLACORTA, JORGE L (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:VILLACORTA
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:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:
Practice Address - Street 1:2404 CHARLES ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1602
Practice Address - Country:US
Practice Address - Phone:779-696-7910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096528Medicaid
IL036096528Medicaid
ILL71898Medicare PIN