Provider Demographics
NPI:1386916138
Name:AVALON PEDIATRICS, INC.
Entity type:Organization
Organization Name:AVALON PEDIATRICS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-474-8700
Mailing Address - Street 1:911 OAK PARK BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3406
Mailing Address - Country:US
Mailing Address - Phone:805-474-8700
Mailing Address - Fax:805-474-8466
Practice Address - Street 1:911 OAK PARK BLVD STE 107
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3406
Practice Address - Country:US
Practice Address - Phone:805-474-8700
Practice Address - Fax:805-474-8466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A647390Medicaid