Provider Demographics
NPI:1467504175
Name:AVERILLA, DIVINA GRACIA (MD)
Entity Type:Individual
Prefix:
First Name:DIVINA
Middle Name:GRACIA
Last Name:AVERILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIVINA
Other - Middle Name:GRACIA
Other - Last Name:AVERILLA-OBENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:8595 S DECATUR BLVD STE 108
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-7006
Practice Address - Country:US
Practice Address - Phone:702-948-1130
Practice Address - Fax:702-688-8861
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7308207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV7308OtherSTATE LICENSE
NV1202877Medicaid
NV1467504175Medicaid