Provider Demographics
NPI:1932461696
Name:AVILA, TAWNY E (DO)
Entity type:Individual
Prefix:DR
First Name:TAWNY
Middle Name:E
Last Name:AVILA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:TAWNY
Other - Middle Name:E
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1355 MARINERS DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-7145
Practice Address - Country:US
Practice Address - Phone:574-267-6778
Practice Address - Fax:574-267-3134
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012011166207Q00000X
IN02004742A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine