Provider Demographics
NPI:1912621459
Name:AVILES, JOVANNY N/A
Entity Type:Individual
Prefix:
First Name:JOVANNY
Middle Name:N/A
Last Name:AVILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10301 GRAND CENTRAL AVE APT 529
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4075
Mailing Address - Country:US
Mailing Address - Phone:845-545-0622
Mailing Address - Fax:
Practice Address - Street 1:4 PARK CENTER CT STE 102
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5613
Practice Address - Country:US
Practice Address - Phone:410-377-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA5725225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty