Provider Demographics
NPI:1992587356
Name:AVILES RIVERA, ANGEL GABRIEL
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:GABRIEL
Last Name:AVILES RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 ROBERT LN BLDG E
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-4467
Mailing Address - Country:US
Mailing Address - Phone:939-419-5994
Mailing Address - Fax:
Practice Address - Street 1:6325 ROBERT LN BLDG E
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-4467
Practice Address - Country:US
Practice Address - Phone:939-419-5994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI46125390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program