Provider Demographics
NPI:1679917280
Name:AVETISOV, GREGORY (DO)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:AVETISOV
Suffix:
Gender:M
Credentials:DO
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 1950
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1950
Mailing Address - Country:US
Mailing Address - Phone:707-263-8383
Mailing Address - Fax:707-263-5019
Practice Address - Street 1:925 BEVINS COURT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8383
Practice Address - Fax:707-263-5019
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17139208D00000X
CA20A22510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice