Provider Demographics
NPI:1083711121
Name:MOURACHOV, PAVEL (MD)
Entity Type:Individual
Prefix:
First Name:PAVEL
Middle Name:
Last Name:MOURACHOV
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 1:3917 WEST RD
Mailing Address - Street 2:STE 137
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544
Mailing Address - Country:US
Mailing Address - Phone:505-661-8500
Mailing Address - Fax:505-661-0096
Practice Address - Street 1:3917 WEST RD
Practice Address - Street 2:STE 137
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-661-8500
Practice Address - Fax:505-661-0096
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD071992L208800000X
NMMD2008-0654208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA081716MLCMedicare ID - Type UnspecifiedMEDICARE PROV NUMBER
PAI12801Medicare UPIN