Provider Demographics
NPI:1518048750
Name:AVILES, OMAR PORFIRIO (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:PORFIRIO
Last Name:AVILES
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 1:161 SAVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2341
Mailing Address - Country:US
Mailing Address - Phone:516-746-5456
Mailing Address - Fax:516-746-3021
Practice Address - Street 1:161 SAVILLE ROAD
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2341
Practice Address - Country:US
Practice Address - Phone:516-746-5456
Practice Address - Fax:516-746-3021
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117301208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
818813Medicare UPIN