Provider Demographics
NPI:1578855409
Name:ANIBAL AVILA MD PROFESSIONAL CORPORATION PC
Entity Type:Organization
Organization Name:ANIBAL AVILA MD PROFESSIONAL CORPORATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANIBAL
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-634-4934
Mailing Address - Street 1:1111 SW 44TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-3601
Mailing Address - Country:US
Mailing Address - Phone:405-634-4934
Mailing Address - Fax:405-634-4938
Practice Address - Street 1:1111 SW 44TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3601
Practice Address - Country:US
Practice Address - Phone:405-634-4934
Practice Address - Fax:405-634-4938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18774261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center