Provider Demographics
NPI:1659735827
Name:AVILA, ANIBAL MIKJAIL (MD)
Entity Type:Individual
Prefix:
First Name:ANIBAL
Middle Name:MIKJAIL
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 1:800 N OKLAHOMA AVE APT 1201
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4407
Mailing Address - Country:US
Mailing Address - Phone:405-763-7098
Mailing Address - Fax:
Practice Address - Street 1:101 S PARK LN
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5731
Practice Address - Country:US
Practice Address - Phone:580-379-6140
Practice Address - Fax:580-379-6149
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK36299207V00000X
TXBP10055824207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200929810AMedicaid