Provider Demographics
NPI:1629430798
Name:BANG, PAVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAVAN
Middle Name:
Last Name:BANG
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 1:166 LYONS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-2016
Mailing Address - Country:US
Mailing Address - Phone:973-926-3533
Mailing Address - Fax:973-923-2978
Practice Address - Street 1:166 LYONS AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2016
Practice Address - Country:US
Practice Address - Phone:973-926-3533
Practice Address - Fax:973-923-2978
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.38597208000000X
NJ25MA10676300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty