Provider Demographics
NPI:1679645071
Name:MARTIN AVILES MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MARTIN AVILES MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:NATCHITOCHES WOMEN'S CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-352-9595
Mailing Address - Street 1:627 BIENVILLE CIR
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5744
Mailing Address - Country:US
Mailing Address - Phone:318-352-9595
Mailing Address - Fax:318-352-9818
Practice Address - Street 1:627 BIENVILLE CIR
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5744
Practice Address - Country:US
Practice Address - Phone:318-352-9595
Practice Address - Fax:318-352-9818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13567R261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DF29OtherGROUP NPI MEDICARE PIN/PTAN
LA5H631DF29OtherMEDICARE GROUP 'MEMBER' PIN/PTAN
LA1417952102OtherINDIVIDUAL PROVIDER NPI #
LA1529877OtherMEDICAID GROUP PROVIDER ID
LADT5115OtherMEDICARE RAILROAD