Healthcare Provider Details

I. General information

NPI: 1982681151
Provider Name (Legal Business Name): VIRGINIA M AVILAHASKELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIA VIRGINIA AVILA M.D.

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 19TH AVE
FAIRBANKS AK
99701-5903
US

IV. Provider business mailing address

PO BOX 73889 DEPT OF FM
FAIRBANKS AK
99707-3889
US

V. Phone/Fax

Practice location:
  • Phone: 310-908-8828
  • Fax:
Mailing address:
  • Phone: 310-908-8828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA89929
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA89929
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6825
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: