Provider Demographics
NPI:1205328978
Name:GOTERA AVILA, ALFREDO JOSE (SA-C)
Entity type:Individual
Prefix:MR
First Name:ALFREDO
Middle Name:JOSE
Last Name:GOTERA AVILA
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11150 NW 82ND ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1760
Mailing Address - Country:US
Mailing Address - Phone:407-820-2693
Mailing Address - Fax:
Practice Address - Street 1:600 NW 35TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-4000
Practice Address - Country:US
Practice Address - Phone:407-820-2693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-182246ZC0007X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant