Provider Demographics
NPI:1396939575
Name:AVILA, SANDRA G (MD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:G
Last Name:AVILA
Suffix:
Gender:F
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-4815
Mailing Address - Fax:323-442-4815
Practice Address - Street 1:1510 SAN PABLO ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5320
Practice Address - Country:US
Practice Address - Phone:323-442-4815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95714207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1770696023Medicaid
CAHAP71129FOtherFAM PLANNING
CAFHC71129FMedicaid