Healthcare Provider Details

I. General information

NPI: 1487334553
Provider Name (Legal Business Name): LIDA AVETISYAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 E SPRUCE AVE
FRESNO CA
93720-3374
US

IV. Provider business mailing address

1111 E SPRUCE AVE STE 431
FRESNO CA
93720-3330
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-5777
  • Fax: 559-450-5687
Mailing address:
  • Phone: 559-450-7449
  • Fax: 559-450-7472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA209872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: