Provider Demographics
NPI:1023508785
Name:AGUILA, IDELMIS M
Entity type:Individual
Prefix:MR
First Name:IDELMIS
Middle Name:M
Last Name:AGUILA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13851 SW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2744
Mailing Address - Country:US
Mailing Address - Phone:786-348-1424
Mailing Address - Fax:
Practice Address - Street 1:13851 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-2744
Practice Address - Country:US
Practice Address - Phone:786-348-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid