Provider Demographics
NPI:1528399144
Name:AVILA, DESIDERIO (MD)
Entity Type:Individual
Prefix:DR
First Name:DESIDERIO
Middle Name:
Last Name:AVILA
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:PO BOX 6423
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85246-6423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15920 S. 48TH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-1003
Practice Address - Country:US
Practice Address - Phone:480-961-2323
Practice Address - Fax:480-961-2325
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42814208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ517238Medicaid
AZZ156195Medicare PIN