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General NPI Number Information
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NPI Number | 1386050805
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Entity Type | Individual
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Provider Name | JONATHAN AVALOS M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/03/2014
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Last Update Date | 01/14/2022
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Provider Practice Location Address
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Address Line | 850 E FOOTHILL BLVD DEPT OF
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City | RIALTO
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State | CA
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Zip | 92376-5230
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Country | US
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Telephone | 909-601-4220
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Fax |
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Provider Business Mailing Address
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Address Line | 303 E VANDERBILT WAY
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City | SAN BERNARDINO
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State | CA
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Zip | 92415-0026
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Country | US
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Telephone | 909-601-4220
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | A139612
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License Number State | CA
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