Provider Demographics
NPI:1487895504
Name:BERTOLI AVELLA, MARIA J (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:J
Last Name:BERTOLI AVELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:J
Other - Last Name:BERTOLI AVELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3610 SW 106TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3627
Mailing Address - Country:US
Mailing Address - Phone:786-395-4635
Mailing Address - Fax:
Practice Address - Street 1:3610 SW 106 AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165
Practice Address - Country:US
Practice Address - Phone:786-395-4635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-19
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114727207ZP0102X, 207ZP0102X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology