Provider Demographics
NPI:1033182977
Name:AVILES, SANDRA R (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:R
Last Name:AVILES
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:PO BOX 4346
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4346
Mailing Address - Country:US
Mailing Address - Phone:210-558-6288
Mailing Address - Fax:210-558-6289
Practice Address - Street 1:520 MADISON OAK DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3913
Practice Address - Country:US
Practice Address - Phone:210-297-9640
Practice Address - Fax:210-297-9640
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ322012080P0203X, 208000000X
IL036-0952752080P0203X
TXL09782080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ832164Medicaid
AZ832164-06Medicaid
IL036095275Medicaid
AZ832164-06Medicaid
IL036095275Medicaid
AZ832164Medicaid