Provider Demographics
NPI:1821089541
Name:AYALA, E T (MD)
Entity Type:Individual
Prefix:
First Name:E
Middle Name:T
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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:
Practice Address - Street 1:92 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4305
Practice Address - Country:US
Practice Address - Phone:920-921-0560
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21604207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12617OtherDEAN
WI21604OtherTOUCHPOINT
WIWI01B2OtherJOHN DEERE
WI30334700Medicaid
B51290Medicare UPIN