Provider Demographics
NPI:1912533787
Name:AVILES FERNANDEZ, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:AVILES FERNANDEZ
Suffix:
Gender:M
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:HC 3 BOX 3628
Mailing Address - Street 2:
Mailing Address - City:FLORIDA
Mailing Address - State:PR
Mailing Address - Zip Code:00650-9692
Mailing Address - Country:US
Mailing Address - Phone:787-949-2961
Mailing Address - Fax:417-765-0144
Practice Address - Street 1:MONACILLO ST 2116
Practice Address - Street 2:CENTRO MEDICO DE PUERTO RICO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00922-2116
Practice Address - Country:US
Practice Address - Phone:787-758-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR35936208600000X
PR15898208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery