Basic Information
| Provider Information | |||||||||
| NPI: | 1184797482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVILA | ||||||||
| FirstName: | MIGUEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7765 NW 48TH ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331665404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054421740 | ||||||||
| FaxNumber: | 3054422207 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 E OAK ST | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347444503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079881035 | ||||||||
| FaxNumber: | 4079881034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 02/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 15988 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN916 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0009858658 | 05 | PR | MEDICAID |