Provider Demographics
NPI:1033101985
Name:AVALOS, MARTIN E (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:E
Last Name:AVALOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 561600
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-1600
Mailing Address - Country:US
Mailing Address - Phone:321-434-4600
Mailing Address - Fax:321-434-4662
Practice Address - Street 1:8725 N WICKHAM RD
Practice Address - Street 2:SUITE 302
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-5997
Practice Address - Country:US
Practice Address - Phone:321-434-9230
Practice Address - Fax:321-434-9231
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79783207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258475100Medicaid
H16013Medicare UPIN
FL258475100Medicaid