MEDICARE: DIVINA GRACIA AVERILLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	7308	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7308	OTHER	NV	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467504175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIVINA GRACIA AVERILLA MD

Provider Business Mailing Address
First Line	:	6355 S BUFFALO DR FL 3
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-2133
Country	:	US
Telephone Number	:	702-216-3346
Fax Number	:	702-671-6883

Provider Business Practice Location Address
First Line	:	8595 S DECATUR BLVD STE 108
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-7006
Country	:	US
Telephone Number	:	702-948-1130
Fax Number	:	702-688-8861

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	10/14/2022

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Directions to “ DIVINA GRACIA AVERILLA MD” Practice Location

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