Provider Demographics
NPI:1700121472
Name:AVULOV, VADIM (DO)
Entity type:Individual
Prefix:DR
First Name:VADIM
Middle Name:
Last Name:AVULOV
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 1:7905 TOMMY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-1833
Mailing Address - Country:US
Mailing Address - Phone:917-602-4507
Mailing Address - Fax:
Practice Address - Street 1:6699 ALVARADO RD STE 2309
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5241
Practice Address - Country:US
Practice Address - Phone:619-396-6637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13344208600000X
MA254605208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110096271AMedicaid
MA110096271AMedicaid