Provider Demographics
NPI:1295020709
Name:AVANESSIAN, EVLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:EVLYN
Middle Name:
Last Name:AVANESSIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3628 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1724
Mailing Address - Country:US
Mailing Address - Phone:818-296-9601
Mailing Address - Fax:818-296-9602
Practice Address - Street 1:3628 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-1724
Practice Address - Country:US
Practice Address - Phone:818-296-9601
Practice Address - Fax:818-296-9602
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA127456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA127456OtherMEDICAL LICENSE