Provider Demographics
NPI:1639190705
Name:SRINIVAS PAVULURI, MD, PA
Entity Type:Organization
Organization Name:SRINIVAS PAVULURI, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVULURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-264-4301
Mailing Address - Street 1:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-0071
Mailing Address - Country:US
Mailing Address - Phone:732-264-4301
Mailing Address - Fax:732-264-1102
Practice Address - Street 1:668 N BEERS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1526
Practice Address - Country:US
Practice Address - Phone:732-264-4301
Practice Address - Fax:732-264-1102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA073415002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
056224U33OtherMEDICARE PTAN#
056224U33OtherMEDICARE PTAN#