Healthcare Provider Details

I. General information

NPI: 1932461696
Provider Name (Legal Business Name): TAWNY ELIZAEBTH AVILA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAWNY ELIZABETH ROSS D.O.

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W TRADE ST STE A
DALLAS NC
28034-1543
US

IV. Provider business mailing address

PO BOX 744786
ATLANTA GA
30374-4786
US

V. Phone/Fax

Practice location:
  • Phone: 980-834-9130
  • Fax: 980-834-9869
Mailing address:
  • Phone: 704-834-2450
  • Fax: 704-671-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2012011166
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2026-04845
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02004742A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: