Basic Information
| Provider Information | |||||||||
| NPI: | 1063611598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVILA | ||||||||
| FirstName: | HUGO | ||||||||
| MiddleName: | HERNANDO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVILA | ||||||||
| OtherFirstName: | HUGO | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | ATTN: CREDENTIALING DEPT | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3730 7TH TER STE 101 | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329606556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725810528 | ||||||||
| FaxNumber: | 8448293327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2007 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | ME 104291 | FL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 009449200 | 05 | FL | MEDICAID |