Provider Demographics
NPI:1831641919
Name:AVENA, ORLANDO
Entity Type:Individual
Prefix:
First Name:ORLANDO
Middle Name:
Last Name:AVENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 NORTH MICHIGAN STREET, SUITE 210
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1069
Mailing Address - Country:US
Mailing Address - Phone:574-233-2114
Mailing Address - Fax:574-288-8921
Practice Address - Street 1:707 NORTH MICHIGAN STREET, SUITE 210
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1069
Practice Address - Country:US
Practice Address - Phone:574-233-2114
Practice Address - Fax:574-288-8921
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005097152W00000X
IN18004002A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300015571Medicaid