Provider Demographics
NPI:1962444836
Name:AVALOS, STEPHEN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:AVALOS
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 2130
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93613-2130
Mailing Address - Country:US
Mailing Address - Phone:559-326-2815
Mailing Address - Fax:559-326-2801
Practice Address - Street 1:305 PARK CREEK DR
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-4426
Practice Address - Country:US
Practice Address - Phone:559-326-2815
Practice Address - Fax:553-326-2801
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56424207ZF0201X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G564240Medicaid
CA220013817OtherRAILROAD MEDICARE
CA220013817OtherRAILROAD MEDICARE
CA00G564240Medicare ID - Type Unspecified