Provider Demographics
NPI:1972568558
Name:AVILA, DUBY EDITH
Entity Type:Individual
Prefix:
First Name:DUBY
Middle Name:EDITH
Last Name:AVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4405
Mailing Address - Country:US
Mailing Address - Phone:407-846-6040
Mailing Address - Fax:407-846-9540
Practice Address - Street 1:1111 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4405
Practice Address - Country:US
Practice Address - Phone:407-846-6040
Practice Address - Fax:407-846-9540
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85055174400000X, 208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No174400000XOther Service ProvidersSpecialist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267601000Medicaid
FL267601000Medicaid
FL51426YMedicare PIN