Provider Demographics
NPI:1861621724
Name:AVILA, MICHELE RENA (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:RENA
Last Name:AVILA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:11820 S STATE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7133
Mailing Address - Country:US
Mailing Address - Phone:801-568-0200
Mailing Address - Fax:801-563-0200
Practice Address - Street 1:11820 S STATE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7133
Practice Address - Country:US
Practice Address - Phone:801-568-0200
Practice Address - Fax:801-563-0200
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS1861152W00000X
OK2594152W00000X
OH5837152W00000X
UT9439507-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist