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General NPI Number Information
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NPI Number | 1679917280
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Entity Type | Individual
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Provider Name | GREGORY AVETISOV DO
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Gender | Male
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Dates
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Enumeration Date | 04/25/2013
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Last Update Date | 01/06/2025
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Provider Practice Location Address
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Address Line | 925 BEVINS COURT
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City | LAKEPORT
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State | CA
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Zip | 95453-9754
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Country | US
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Telephone | 707-263-8383
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Fax | 707-263-5019
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Provider Business Mailing Address
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Address Line | PO BOX 1950
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City | LAKEPORT
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State | CA
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Zip | 95453-1950
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Country | US
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Telephone | 707-263-8383
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Fax | 707-263-5019
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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 | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | OS17139
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 20A22510
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License Number State | CA
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