Provider Demographics
NPI:1134145071
Name:AVILA, SUZANNE (DO, FACEP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:AVILA
Suffix:
Gender:F
Credentials:DO, FACEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 FORT WORTH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2459
Mailing Address - Country:US
Mailing Address - Phone:361-225-2255
Mailing Address - Fax:
Practice Address - Street 1:3240 FORT WORTH ST STE 100
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2459
Practice Address - Country:US
Practice Address - Phone:361-225-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4028207P00000X, 207Q00000X
IL036064093207P00000X
MI5101007493207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131995611Medicaid
TX131995611Medicaid