Provider Demographics
NPI:1760430367
Name:AVILA, EDUARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:EDUARDO
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 1:98 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1758
Mailing Address - Country:US
Mailing Address - Phone:208-782-3993
Mailing Address - Fax:208-782-3994
Practice Address - Street 1:98 POPLAR ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1758
Practice Address - Country:US
Practice Address - Phone:208-782-3993
Practice Address - Fax:208-782-3994
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9388208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID75390OtherBLUE CROSS OLD
ID000010151099OtherREGENCE BLUE SHEILD
IDHB400OtherBLUE CROSS
ID243412OtherALTIUS OLD
ID313067OtherALTIUS
ID243412OtherALTIUS OLD
IDHB400OtherBLUE CROSS
H86003Medicare UPIN
ID1131130Medicare PIN