Provider Demographics
NPI:1952345944
Name:AYALA, IVAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:S
Last Name:AYALA
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:PO BOX 193222
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-3222
Mailing Address - Country:US
Mailing Address - Phone:787-781-0250
Mailing Address - Fax:787-749-0826
Practice Address - Street 1:CARR #21 BLQ U3#8
Practice Address - Street 2:LAS LOMAS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:787-707-0542
Practice Address - Fax:787-749-0826
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR9949207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE67438Medicare UPIN
PR83779Medicare ID - Type Unspecified