Provider Demographics
NPI:1710970710
Name:AYALA, RAUL ERNESTO (MD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:ERNESTO
Last Name:AYALA
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 1:10508 GIBSONTON DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-5434
Mailing Address - Country:US
Mailing Address - Phone:813-741-2100
Mailing Address - Fax:813-741-2003
Practice Address - Street 1:10508 GIBSONTON DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5434
Practice Address - Country:US
Practice Address - Phone:813-741-2100
Practice Address - Fax:813-741-2003
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79510208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002218500Medicaid
FLH367570001Medicare UPIN
FLE5532XMedicare PIN