Healthcare Provider Details

I. General information

NPI: 1679917280
Provider Name (Legal Business Name): GREGORY AVETISOV DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2013
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 BEVINS COURT
LAKEPORT CA
95453-9754
US

IV. Provider business mailing address

PO BOX 1950
LAKEPORT CA
95453-1950
US

V. Phone/Fax

Practice location:
  • Phone: 707-263-8383
  • Fax: 707-263-5019
Mailing address:
  • Phone: 707-263-8383
  • Fax: 707-263-5019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS17139
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A22510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: