Provider Demographics
NPI:1235414020
Name:AVELLA, VICTOR JOSE (AA-C)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:JOSE
Last Name:AVELLA
Suffix:
Gender:M
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 MASSACHUSETTS AVE NW APT 1007
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-7631
Mailing Address - Country:US
Mailing Address - Phone:305-494-5638
Mailing Address - Fax:
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-3017
Practice Address - Country:US
Practice Address - Phone:202-877-7504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCAA000030367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC027447100Medicaid
DCG00513Medicare PIN