Healthcare Provider Details

I. General information

NPI: 1033885199
Provider Name (Legal Business Name): AVENUE MEDICAL WELLNESS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 5TH AVE RM 603
NEW YORK NY
10017-8009
US

IV. Provider business mailing address

535 5TH AVE RM 603
NEW YORK NY
10017-8009
US

V. Phone/Fax

Practice location:
  • Phone: 310-614-3697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BOJANA JANKOVIC WEATHERLY
Title or Position: OWNER
Credential: MD
Phone: 310-614-3697