Provider Demographics
NPI:1043292295
Name:AVILA, RICHARD JR (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:AVILA
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5402 S STAPLES ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-4656
Mailing Address - Country:US
Mailing Address - Phone:361-992-9400
Mailing Address - Fax:361-992-8295
Practice Address - Street 1:5402 S STAPLES ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4656
Practice Address - Country:US
Practice Address - Phone:361-992-9400
Practice Address - Fax:361-992-8295
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX05221TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU62285Medicare UPIN
TX85X608Medicare ID - Type Unspecified