Provider Demographics
NPI:1235245937
Name:PAVOURIS, NICOLAS (MD)
Entity Type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:
Last Name:PAVOURIS
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 1:10051 5TH STREET NORTH #200
Mailing Address - Street 2:JSA HEALTHCARE CORPORATION
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2211
Mailing Address - Country:US
Mailing Address - Phone:727-828-2376
Mailing Address - Fax:727-568-6011
Practice Address - Street 1:1200 S. PINELLAS AVE # 11
Practice Address - Street 2:JSA TARPON SOUTH PRIMARY CARE CENTER
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3716
Practice Address - Country:US
Practice Address - Phone:727-942-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77322207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009910000Medicaid
FL28091VMedicare PIN
FL009910000Medicaid