Provider Demographics
NPI:1922452762
Name:ELLIOTT, AVALON (DO)
Entity Type:Individual
Prefix:DR
First Name:AVALON
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:AVALON
Other - Middle Name:
Other - Last Name:NEWSOME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR LBBY J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:
Practice Address - Street 1:4350 JACKSON RD STE 200
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-1889
Practice Address - Country:US
Practice Address - Phone:734-761-2581
Practice Address - Fax:734-761-9540
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101024401207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine