Provider Demographics
NPI:1902825094
Name:MAHADASS, PAVANI (MD)
Entity Type:Individual
Prefix:MRS
First Name:PAVANI
Middle Name:
Last Name:MAHADASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MICHAEL WAY
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534-9606
Mailing Address - Country:US
Mailing Address - Phone:609-737-3811
Mailing Address - Fax:609-737-3080
Practice Address - Street 1:22 MICHAEL WAY
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-9606
Practice Address - Country:US
Practice Address - Phone:609-737-3811
Practice Address - Fax:609-737-3080
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03118700208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1390503Medicaid
C52674Medicare UPIN
NJ1390503Medicaid