Provider Demographics
NPI:1649286014
Name:AVINA, ALONSO H (LPT)
Entity type:Individual
Prefix:MR
First Name:ALONSO
Middle Name:H
Last Name:AVINA
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10015 MELVINA AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3711
Mailing Address - Country:US
Mailing Address - Phone:773-370-7675
Mailing Address - Fax:
Practice Address - Street 1:10015 MELVINA AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3711
Practice Address - Country:US
Practice Address - Phone:773-370-7675
Practice Address - Fax:708-499-0322
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
ILK03982/208324Medicare PIN
IL$$$$$$$$$001Medicaid
ILK03983/208325Medicare ID - Type UnspecifiedMCARE LOC 16
ILK03983/208325Medicare PIN