Provider Demographics
NPI:1689711756
Name:AVON, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:AVON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1450 TREAT BLVD # 300
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:925-952-2828
Mailing Address - Fax:
Practice Address - Street 1:5201 NORRIS CANYON RD STE 210
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5405
Practice Address - Country:US
Practice Address - Phone:925-830-1140
Practice Address - Fax:925-973-0976
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA43035208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43035OtherCA MEDICAL LICENSE
CA00A430350Medicaid
CA00A430350Medicare ID - Type Unspecified
CA00A430350Medicaid