Provider Demographics
NPI:1578593943
Name:AVERELL, PAUL JOHN (IDC)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:JOHN
Last Name:AVERELL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 SCHUBERT DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6644
Mailing Address - Country:US
Mailing Address - Phone:757-314-7198
Mailing Address - Fax:
Practice Address - Street 1:1550 TOMCAT BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23460
Practice Address - Country:US
Practice Address - Phone:757-314-7198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient