Provider Demographics
NPI:1255531992
Name:AVILES, FERNANDO JOSE (MD)
Entity type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:JOSE
Last Name:AVILES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FERNANDO
Other - Middle Name:JOSE
Other - Last Name:AVILES-CEVASCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10412 VISTA DEL SOL DR STE 1B
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-7937
Mailing Address - Country:US
Mailing Address - Phone:915-593-9300
Mailing Address - Fax:915-593-9310
Practice Address - Street 1:11450 GATEWAY BLVD N STE 2200
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79934-3456
Practice Address - Country:US
Practice Address - Phone:915-440-3700
Practice Address - Fax:915-440-3701
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7210146D00000X, 261QP2300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45-1985Medicare PIN