Provider Demographics
NPI:1033118260
Name:PAVAN, JAY (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:PAVAN
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 1:13000 RIVERS BEND BLVD
Mailing Address - Street 2:STE D
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-8632
Mailing Address - Country:US
Mailing Address - Phone:804-571-5106
Mailing Address - Fax:804-530-1857
Practice Address - Street 1:325 CHARLES H DIMMOCK PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2986
Practice Address - Country:US
Practice Address - Phone:804-526-5888
Practice Address - Fax:804-526-5401
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101222130208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA200039821OtherRAILROAD MEDICARE
VA006800530Medicaid
VA200039821OtherRAILROAD MEDICARE
VA006800530Medicaid
VA0603180002Medicare NSC