Basic Information
| Provider Information | |||||||||
| NPI: | 1932461696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVILA | ||||||||
| FirstName: | TAWNY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSS | ||||||||
| OtherFirstName: | TAWNY | ||||||||
| OtherMiddleName: | E. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 51711 WINDYRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466289554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142518950 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 LINCOLNWAY | ||||||||
| Address2: | C/O NOEMI RODGERS | ||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193262461 | ||||||||
| FaxNumber: | 2193262584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2012 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02004742A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2012011166 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.