Provider Demographics
NPI:1144427584
Name:MALLUR, PAVAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:PAVAN
Middle Name:S
Last Name:MALLUR
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 1:110 FRANCIS ST
Mailing Address - Street 2:SUITE 6E
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5501
Mailing Address - Country:US
Mailing Address - Phone:617-632-7509
Mailing Address - Fax:
Practice Address - Street 1:110 FRANCIS ST
Practice Address - Street 2:SUITE 6E
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5501
Practice Address - Country:US
Practice Address - Phone:617-632-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247305207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology