Healthcare Provider Details

I. General information

NPI: 1376406421
Provider Name (Legal Business Name): MARIO LUIS AVILA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 W GEOGIA
ANADARKO OK
73005
US

IV. Provider business mailing address

712 W GEOGIA
ANADARKO OK
73005
US

V. Phone/Fax

Practice location:
  • Phone: 760-224-9296
  • Fax:
Mailing address:
  • Phone: 760-224-9296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: