Provider Demographics
NPI:1710249503
Name:MURTY, PAVAN VABILISETTI (MD)
Entity Type:Individual
Prefix:
First Name:PAVAN
Middle Name:VABILISETTI
Last Name:MURTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1875 DEMPSTER ST STE 625
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1137
Mailing Address - Country:US
Mailing Address - Phone:847-723-4088
Mailing Address - Fax:847-627-8700
Practice Address - Street 1:1875 DEMPSTER ST STE 625
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1137
Practice Address - Country:US
Practice Address - Phone:847-723-4088
Practice Address - Fax:847-627-8700
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1428412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty