Provider Demographics
NPI:1730556663
Name:DAVILA, AIDA
Entity type:Individual
Prefix:
First Name:AIDA
Middle Name:
Last Name:DAVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 PINE LN
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-2601
Mailing Address - Country:US
Mailing Address - Phone:516-603-2843
Mailing Address - Fax:
Practice Address - Street 1:34 W 139TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1508
Practice Address - Country:US
Practice Address - Phone:212-632-4532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231640201390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program