Provider Demographics
NPI:1659464139
Name:AVEDISIAN, ARA ANTHONY
Entity Type:Individual
Prefix:
First Name:ARA
Middle Name:ANTHONY
Last Name:AVEDISIAN
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 1:346 MAPLE AVE. WEST
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180
Mailing Address - Country:US
Mailing Address - Phone:703-242-1415
Mailing Address - Fax:
Practice Address - Street 1:346 MAPLE AVE. WEST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180
Practice Address - Country:US
Practice Address - Phone:703-242-1415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VADC006248L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA015392OtherANTHEM PROVIDER NUMBER
VAG665-0001OtherCAREFIRST PROVIDER NUMBER