Healthcare Provider Details

I. General information

NPI: 1710970710
Provider Name (Legal Business Name): RAUL ERNESTO AYALA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 12/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10508 GIBSONTON DR
RIVERVIEW FL
33569-5434
US

IV. Provider business mailing address

10508 GIBSONTON DR
RIVERVIEW FL
33578-5434
US

V. Phone/Fax

Practice location:
  • Phone: 813-741-2100
  • Fax: 813-741-2003
Mailing address:
  • Phone: 813-741-2100
  • Fax: 813-741-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME79510
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: