Healthcare Provider Details

I. General information

NPI: 1780244848
Provider Name (Legal Business Name): JAVIER R AYALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20646 WILDERNESS LAKE BLVD
LAND O LAKES FL
34637-7861
US

IV. Provider business mailing address

20646 WILDERNESS LAKE BLVD
LAND O LAKES FL
34637-7861
US

V. Phone/Fax

Practice location:
  • Phone: 813-996-4932
  • Fax: 813-996-9713
Mailing address:
  • Phone: 813-996-4932
  • Fax: 813-996-9713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME155736
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: