Provider Demographics
NPI:1255020947
Name:AVILA ZALDIVAR, JOSE LUIS (MD, SA-C)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:AVILA ZALDIVAR
Suffix:
Gender:M
Credentials:MD, SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 W 54TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-2014
Mailing Address - Country:US
Mailing Address - Phone:954-914-5861
Mailing Address - Fax:
Practice Address - Street 1:7031 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4701
Practice Address - Country:US
Practice Address - Phone:305-284-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23338246ZC0007X
FLTRN42149390200000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program