Provider Demographics
NPI:1457768731
Name:EVLYN AVANESSIAN, MD, INC
Entity Type:Organization
Organization Name:EVLYN AVANESSIAN, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:EVLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:AVANESSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-352-3146
Mailing Address - Street 1:3628 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1724
Mailing Address - Country:US
Mailing Address - Phone:818-296-9601
Mailing Address - Fax:818-296-9602
Practice Address - Street 1:3628 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-1724
Practice Address - Country:US
Practice Address - Phone:818-296-9601
Practice Address - Fax:818-296-9602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
CAA127456261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty