Healthcare Provider Details

I. General information

NPI: 1205681855
Provider Name (Legal Business Name): AVIS KO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2024
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1731 E 120TH ST
LOS ANGELES CA
90059-3051
US

IV. Provider business mailing address

119 E COLORADO AVE
GLENDORA CA
91740-4411
US

V. Phone/Fax

Practice location:
  • Phone: 323-563-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number3922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: