Provider Demographics
NPI:1588462758
Name:AVILES, SAMUEL (CSFA)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:AVILES
Suffix:
Gender:
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11506 ECHO LAKE CIR UNIT 305
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-2504
Mailing Address - Country:US
Mailing Address - Phone:941-705-4700
Mailing Address - Fax:
Practice Address - Street 1:7171 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2665
Practice Address - Country:US
Practice Address - Phone:813-932-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL209101246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant