Healthcare Provider Details

I. General information

NPI: 1104839596
Provider Name (Legal Business Name): ISRAEL AVILES HERNANDEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 2, KM 81, MARGINAL, REPARTO SAN MIGUEL
ARECIBO PR
00612-1299
US

IV. Provider business mailing address

PO BOX 2439
VEGA BAJA PR
00694-2439
US

V. Phone/Fax

Practice location:
  • Phone: 787-878-4143
  • Fax: 787-879-4143
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0004X
TaxonomySpinal Cord Injury Medicine Physician
License Number14777
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: