1477742740 NPI number — DUBY AVILA M.D. P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477742740 NPI number — DUBY AVILA M.D. P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUBY AVILA M.D. P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1477742740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 N CENTRAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KISSIMMEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34741-4405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-846-6040
Provider Business Mailing Address Fax Number:
407-846-9540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34741-4405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-846-6040
Provider Business Practice Location Address Fax Number:
407-846-9540
Provider Enumeration Date:
10/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AVILA
Authorized Official First Name:
DUBY
Authorized Official Middle Name:
EDITH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-846-6040

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME85055 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 014660400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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