=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710970710
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAUL ERNESTO AYALA M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2005
-----------------------------------------------------
Last Update Date | 12/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10508 GIBSONTON DR
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33569-5434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-741-2100
-----------------------------------------------------
Fax | 813-741-2003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10508 GIBSONTON DR
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33578-5434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-741-2100
-----------------------------------------------------
Fax | 813-741-2003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ME79510
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------