Provider Demographics
NPI:1801373634
Name:GAVILLA, JORGE (PTA)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:GAVILLA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 W 76TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3422
Mailing Address - Country:US
Mailing Address - Phone:786-230-6296
Mailing Address - Fax:
Practice Address - Street 1:2600 NW 87TH AVE STE 22
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-1619
Practice Address - Country:US
Practice Address - Phone:305-592-5555
Practice Address - Fax:305-592-6067
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28361225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant