Provider Demographics
NPI:1114412467
Name:DAVE, PAULOMI MANOJ
Entity Type:Individual
Prefix:
First Name:PAULOMI
Middle Name:MANOJ
Last Name:DAVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 ALTAMONT PLACE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695
Mailing Address - Country:US
Mailing Address - Phone:240-518-6030
Mailing Address - Fax:240-518-6031
Practice Address - Street 1:4240 ALTAMONT PLACE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695
Practice Address - Country:US
Practice Address - Phone:240-518-6030
Practice Address - Fax:240-518-6031
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD96132207R00000X, 207RE0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD266951000Medicaid