Provider Demographics
NPI:1285677948
Name:JAVELLANA, ERONICO P
Entity Type:Individual
Prefix:
First Name:ERONICO
Middle Name:P
Last Name:JAVELLANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2864 ASHMUN ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3740
Mailing Address - Country:US
Mailing Address - Phone:906-632-5200
Mailing Address - Fax:906-632-5276
Practice Address - Street 1:2864 ASHMUN ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3740
Practice Address - Country:US
Practice Address - Phone:906-632-5200
Practice Address - Fax:906-632-5276
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI33553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine