Healthcare Provider Details

I. General information

NPI: 1053359976
Provider Name (Legal Business Name): ROGER AVILES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 PARKLAWN AVE
EDINA MN
55435-5655
US

IV. Provider business mailing address

4008 GRIMES AVE S
EDINA MN
55416-5060
US

V. Phone/Fax

Practice location:
  • Phone: 953-831-4454
  • Fax:
Mailing address:
  • Phone: 612-308-2319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number44640
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: