Provider Demographics
NPI:1700819208
Name:PAVON, ALEX R (MD)
Entity Type:Individual
Prefix:MR
First Name:ALEX
Middle Name:R
Last Name:PAVON
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 1:81 ERIE ST
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-3403
Mailing Address - Country:US
Mailing Address - Phone:201-384-6306
Mailing Address - Fax:
Practice Address - Street 1:534 W 135TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-8601
Practice Address - Country:US
Practice Address - Phone:212-491-2300
Practice Address - Fax:212-491-2323
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199925-1207R00000X
NJ25MA07135200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
01000776801OtherAMERICHOICE
NY01663583Medicaid
NJ8224329OtherGHI
NJ3K3007OtherHEALTHNET
NJ0078191Medicaid
NJ092881U2ZMedicare PIN
NYG21738Medicare UPIN
NJ0078191Medicaid