Provider Demographics
NPI:1437717808
Name:AVILA, LISA M (DC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:AVILA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E 28TH ST RM 405
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-8445
Mailing Address - Country:US
Mailing Address - Phone:212-532-6500
Mailing Address - Fax:
Practice Address - Street 1:118 E 28TH ST
Practice Address - Street 2:RM 405
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-532-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009197111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY134115903OtherPRIVATE INSURANCE