Provider Demographics
NPI:1336106335
Name:AVRITT, PAUL DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DEAN
Last Name:AVRITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2432
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-2432
Mailing Address - Country:US
Mailing Address - Phone:505-898-6064
Mailing Address - Fax:
Practice Address - Street 1:801 VASSAR DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2725
Practice Address - Country:US
Practice Address - Phone:505-248-4052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87-203208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB0007Medicaid