Healthcare Provider Details

I. General information

NPI: 1093880403
Provider Name (Legal Business Name): ALBERTO JULIAN AVILES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29201 TELEGRAPH RD STE 200
SOUTHFIELD MI
48034-7645
US

IV. Provider business mailing address

29201 TELEGRAPH RD STE 200
SOUTHFIELD MI
48034-7645
US

V. Phone/Fax

Practice location:
  • Phone: 249-936-0067
  • Fax: 248-716-5955
Mailing address:
  • Phone: 248-936-0067
  • Fax: 248-716-5955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number4301087507
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301087507
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number4301087507
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: