Provider Demographics
NPI:1073621827
Name:AVILA, REUBEN WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:REUBEN
Middle Name:WILLIAM
Last Name:AVILA
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 1:6799 GREAT OAKS RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2588
Mailing Address - Country:US
Mailing Address - Phone:901-821-8300
Mailing Address - Fax:901-261-0701
Practice Address - Street 1:6799 GREAT OAKS RD
Practice Address - Street 2:SUITE 250
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38138-2588
Practice Address - Country:US
Practice Address - Phone:901-821-8300
Practice Address - Fax:901-261-0701
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD13140207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3382217Medicaid
110001727OtherRAILROAD MEDICARE
0020052OtherBLUE CROSS
B04236Medicare UPIN