Provider Demographics
NPI:1457469991
Name:AVILA, JAY (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:AVILA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1185
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-0820
Mailing Address - Country:US
Mailing Address - Phone:951-505-5674
Mailing Address - Fax:
Practice Address - Street 1:10326 SPARKLING DR 2
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0335
Practice Address - Country:US
Practice Address - Phone:951-929-6260
Practice Address - Fax:714-312-5864
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8829207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A233240Medicaid