Provider Demographics
NPI:1366026106
Name:SURTI, PAVAN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PAVAN
Middle Name:
Last Name:SURTI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6742 LAKEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-1437
Mailing Address - Country:US
Mailing Address - Phone:630-386-6612
Mailing Address - Fax:
Practice Address - Street 1:6742 LAKEVIEW CT
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1437
Practice Address - Country:US
Practice Address - Phone:630-386-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center