Provider Demographics
NPI:1528321130
Name:AVILA, MARCELA VIVIANA
Entity type:Individual
Prefix:
First Name:MARCELA
Middle Name:VIVIANA
Last Name:AVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 NW 23RD BLVD
Mailing Address - Street 2:APT 213
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-3080
Mailing Address - Country:US
Mailing Address - Phone:925-325-0955
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:NF/SG VHS GRECC #182
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-548-6000
Practice Address - Fax:352-271-4550
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 122195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019557500Medicaid
FLIV675ZMedicare PIN