1205039104 NPI number — DR. CRISTOBAL ANTRON AVILA M.D

Table of content: DR. CRISTOBAL ANTRON AVILA M.D (NPI 1205039104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205039104 NPI number — DR. CRISTOBAL ANTRON AVILA M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANTRON AVILA
Provider First Name:
CRISTOBAL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205039104
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PMB 108 PO. BOX 70005
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAJARDO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00738-0005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-887-1819
Provider Business Mailing Address Fax Number:
787-888-0202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
URB. BRISAS DEL MAR
Provider Second Line Business Practice Location Address:
EDIFICIO SONNY CITY CALLE 2-J-6
Provider Business Practice Location Address City Name:
LUQUILLO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00738-0005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
939-640-6095
Provider Business Practice Location Address Fax Number:
787-888-0202
Provider Enumeration Date:
06/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  10988 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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