Healthcare Provider Details

I. General information

NPI: 1902896145
Provider Name (Legal Business Name): RAYMOND VIDAL AVILES DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDIFICIO MARVESA 472 AVE TITO CASTRO SUITE 405
PONCE PR
00716
US

IV. Provider business mailing address

PO BOX 7575
PONCE PR
00732-7575
US

V. Phone/Fax

Practice location:
  • Phone: 787-848-6221
  • Fax: 787-848-6221
Mailing address:
  • Phone: 787-848-6221
  • Fax: 787-848-6221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0096
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: