Provider Demographics
NPI:1710999628
Name:AVIN, ILAN D (MD)
Entity Type:Individual
Prefix:
First Name:ILAN
Middle Name:D
Last Name:AVIN
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2104 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1522
Practice Address - Country:US
Practice Address - Phone:704-377-3900
Practice Address - Fax:704-377-1244
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-02326208600000X
WAML20007818208600000X
FLME1065912086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology