Healthcare Provider Details

I. General information

NPI: 1245455690
Provider Name (Legal Business Name): AVIVA L. FAX MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

2422 CLAVER RD
UNIVERSITY HEIGHTS OH
44118-4631
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-1117
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.093417
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: