Provider Demographics
NPI:1710921051
Name:AVOLESE, SEBASTIAN PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:PAUL
Last Name:AVOLESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7309 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7431
Mailing Address - Country:US
Mailing Address - Phone:718-821-4919
Mailing Address - Fax:718-366-0609
Practice Address - Street 1:7309 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7431
Practice Address - Country:US
Practice Address - Phone:718-821-4919
Practice Address - Fax:718-366-0609
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142031208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00480722Medicaid
NYB12135Medicare UPIN
NY00480722Medicaid