Provider Demographics
NPI:1013278944
Name:AVAGYAN, JULETTA (MD)
Entity Type:Individual
Prefix:DR
First Name:JULETTA
Middle Name:
Last Name:AVAGYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6722
Mailing Address - Country:US
Mailing Address - Phone:618-463-7240
Mailing Address - Fax:618-463-7216
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:618-463-7240
Practice Address - Fax:618-463-7216
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026284207Q00000X, 208M00000X
IL036-144670208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA207QOOOOOXOtherFAMILY MEDICINE