Healthcare Provider Details

I. General information

NPI: 1457768731
Provider Name (Legal Business Name): EVLYN AVANESSIAN, MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3628 FOOTHILL BLVD
LA CRESCENTA CA
91214-1724
US

IV. Provider business mailing address

3628 FOOTHILL BLVD
LA CRESCENTA CA
91214-1724
US

V. Phone/Fax

Practice location:
  • Phone: 818-296-9601
  • Fax: 818-296-9602
Mailing address:
  • Phone: 818-296-9601
  • Fax: 818-296-9602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberA127456
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: EVLYN AVANESSIAN
Title or Position: MD
Credential: MD
Phone: 818-352-3146