Provider Demographics
NPI:1548249469
Name:VILLAFUERTE, LYDIA SIMEONA Q (MD)
Entity type:Individual
Prefix:
First Name:LYDIA SIMEONA
Middle Name:Q
Last Name:VILLAFUERTE
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 1:2950 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5904
Mailing Address - Country:US
Mailing Address - Phone:217-588-7450
Mailing Address - Fax:217-588-7483
Practice Address - Street 1:2950 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5904
Practice Address - Country:US
Practice Address - Phone:217-588-7450
Practice Address - Fax:217-588-7483
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089825207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089825Medicaid
IL036089825Medicaid
G05696OtherTRICARE
ILK15111Medicare ID - Type Unspecified
IL05930221OtherBLUE CROSS BLUE SHIELD
227328OtherGHP
P00195440Medicare ID - Type UnspecifiedRAILROAD MEDICARE
ILG05696Medicare UPIN
017669OtherHEALTH ALLIANCE