Healthcare Provider Details

I. General information

NPI: 1386050805
Provider Name (Legal Business Name): JONATHAN AVALOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 01/14/2022
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E FOOTHILL BLVD DEPT OF
RIALTO CA
92376-5230
US

IV. Provider business mailing address

303 E VANDERBILT WAY
SAN BERNARDINO CA
92415-0026
US

V. Phone/Fax

Practice location:
  • Phone: 909-601-4220
  • Fax:
Mailing address:
  • Phone: 909-601-4220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberA139612
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: