Basic Information
| Provider Information | |||||||||
| NPI: | 1154707875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISLA CUEVAS | ||||||||
| FirstName: | ABIEZER | ||||||||
| MiddleName: | NATANAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948652 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 E OAK AVE | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932915034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8779603426 | ||||||||
| FaxNumber: | 5597341247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2015 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | N | Hospitals | General Acute Care Hospital | 208000000X | MD209159 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | A154728 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1154707875 | 05 | CA | MEDICAID |