Provider Demographics
NPI:1366646069
Name:AVALLONE, AARON G
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:G
Last Name:AVALLONE
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 1:1330 QUAIL LAKE LOOP
Mailing Address - Street 2:STE 260
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4651
Mailing Address - Country:US
Mailing Address - Phone:719-540-2100
Mailing Address - Fax:719-540-2102
Practice Address - Street 1:1330 QUAIL LAKE LOOP STE 260
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906
Practice Address - Country:US
Practice Address - Phone:719-464-6752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00574012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN