Provider Demographics
NPI:1811972847
Name:AREVALO, PABLO A (MD)
Entity type:Individual
Prefix:DR
First Name:PABLO
Middle Name:A
Last Name:AREVALO
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 1:8903 GUATEMALA AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90240-2036
Mailing Address - Country:US
Mailing Address - Phone:323-588-5157
Mailing Address - Fax:323-588-6878
Practice Address - Street 1:3400 E FLORENCE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5835
Practice Address - Country:US
Practice Address - Phone:323-588-5157
Practice Address - Fax:323-588-6878
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44797174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A447970Medicaid
CAA44797Medicare ID - Type Unspecified
CA00A447970Medicaid