Provider Demographics
NPI:1912296971
Name:AVALOS, JOSEPH ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ANTHONY
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 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:619-471-9186
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DRIVE
Practice Address - Street 2:MC8485
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-8485
Practice Address - Country:US
Practice Address - Phone:619-471-9198
Practice Address - Fax:619-543-8255
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-30
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA143574208M00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04505760Medicaid
LA2146513Medicaid
LA365722YH3UMedicare PIN