Provider Demographics
NPI:1730279621
Name:AVELLINO, ANTHONY M (MD, MBA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:M
Last Name:AVELLINO
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 N CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85724-5070
Mailing Address - Country:US
Mailing Address - Phone:520-626-2164
Mailing Address - Fax:
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-8761
Practice Address - Country:US
Practice Address - Phone:520-626-2164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301115254207T00000X
WAMD00033972207T00000X
AZ66853207T00000X
CAG175077207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1730279621Medicaid
WA0252115OtherL&I
590OtherINTERNAL ID-MOTOR VEHICLE ID
WA1730279621Medicaid
G89546Medicare UPIN