Provider Demographics
NPI:1225080039
Name:JOSE L AVILA MD PA
Entity Type:Organization
Organization Name:JOSE L AVILA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-956-7755
Mailing Address - Street 1:413 TAMARIND DR
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-6541
Mailing Address - Country:US
Mailing Address - Phone:305-956-7755
Mailing Address - Fax:305-956-5688
Practice Address - Street 1:1380 NE MIAMI GARDENS DR
Practice Address - Street 2:SUITE 132
Practice Address - City:N MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-4707
Practice Address - Country:US
Practice Address - Phone:305-956-7755
Practice Address - Fax:305-956-5688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77537207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257282600Medicaid
FLH15478Medicare UPIN
FL257282600Medicaid