Provider Demographics
NPI:1154847895
Name:PAVLOV, ANDREW JOSEPH (PT, DPT, CSCS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOSEPH
Last Name:PAVLOV
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1084 N. EL CAMINO REAL
Mailing Address - Street 2:B-351
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024
Mailing Address - Country:US
Mailing Address - Phone:760-918-9200
Mailing Address - Fax:760-918-9203
Practice Address - Street 1:4635 MISSION GORGE PL STE B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4145
Practice Address - Country:US
Practice Address - Phone:619-501-9037
Practice Address - Fax:619-501-9038
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA293463OtherCA PT LICENSE