Provider Demographics
NPI:1043830045
Name:AVILES, DIEGO (MD)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:AVILES
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 1:100 E 33RD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-2776
Mailing Address - Country:US
Mailing Address - Phone:360-514-7550
Mailing Address - Fax:
Practice Address - Street 1:4545 CORDATA PKWY STE 2C
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-7264
Practice Address - Country:US
Practice Address - Phone:360-752-5165
Practice Address - Fax:360-752-5686
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD61425471207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program