Provider Demographics
NPI:1497830897
Name:AYALA, IVAN LUIS (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:LUIS
Last Name:AYALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SW 84TH AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2729
Mailing Address - Country:US
Mailing Address - Phone:954-452-0774
Mailing Address - Fax:
Practice Address - Street 1:220 SW 84TH AVE STE 106
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2729
Practice Address - Country:US
Practice Address - Phone:954-452-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME50619207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease