Healthcare Provider Details

I. General information

NPI: 1497198865
Provider Name (Legal Business Name): JEREMY SCOTT AVILA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6799 GREAT OAKS RD STE 105
MEMPHIS TN
38138-2572
US

IV. Provider business mailing address

6799 GREAT OAKS RD STE 105
MEMPHIS TN
38138-2572
US

V. Phone/Fax

Practice location:
  • Phone: 901-821-8300
  • Fax: 901-261-0718
Mailing address:
  • Phone: 901-821-8300
  • Fax: 901-261-0718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number55874
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number55874
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: