Provider Demographics
NPI:1184860926
Name:IRUKULLA, PAVAN K (MD)
Entity Type:Individual
Prefix:
First Name:PAVAN
Middle Name:K
Last Name:IRUKULLA
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 1:404 TERRACE MNR
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2383
Mailing Address - Country:US
Mailing Address - Phone:570-687-8786
Mailing Address - Fax:570-969-7421
Practice Address - Street 1:1800 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-2369
Practice Address - Country:US
Practice Address - Phone:570-969-8000
Practice Address - Fax:570-969-7421
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD435885207R00000X
TXR1780207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine