Provider Demographics
NPI:1083977342
Name:VAJRAVELU, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VAJRAVELU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 PENN AVE
Mailing Address - Street 2:FACULTY PAVILION 6TH FLOOR
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224
Mailing Address - Country:US
Mailing Address - Phone:412-692-5170
Mailing Address - Fax:412-692-5834
Practice Address - Street 1:4401 PENN AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-1334
Practice Address - Country:US
Practice Address - Phone:412-692-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT201169208000000X
PAMD4543792080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034873410002Medicaid