Provider Demographics
NPI:1790765428
Name:AVILLA, RODNEY J (DO)
Entity Type:Individual
Prefix:MR
First Name:RODNEY
Middle Name:J
Last Name:AVILLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 GEER RD
Mailing Address - Street 2:#303
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382
Mailing Address - Country:US
Mailing Address - Phone:209-632-3966
Mailing Address - Fax:209-667-4168
Practice Address - Street 1:2101 GEER RD
Practice Address - Street 2:#303
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382
Practice Address - Country:US
Practice Address - Phone:209-632-3966
Practice Address - Fax:209-667-4168
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX54870Medicaid
E08919Medicare UPIN
CA00AX54870Medicaid