Basic Information
| Provider Information | |||||||||
| NPI: | 1689711756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 TREAT BLVD # 300 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945972168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259522828 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5201 NORRIS CANYON RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | SAN RAMON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945835405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9258301140 | ||||||||
| FaxNumber: | 9259730976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | A43035 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | A43035 | 01 | CA | CA MEDICAL LICENSE | OTHER | 00A430350 | 05 | CA | MEDICAID |