Provider Demographics
NPI:1942465950
Name:CAVALLARO, NICHOLAS S (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:S
Last Name:CAVALLARO
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 1:2301 S. BROAD STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148
Mailing Address - Country:US
Mailing Address - Phone:215-952-9434
Mailing Address - Fax:
Practice Address - Street 1:2301 S. BROAD STREET
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148
Practice Address - Country:US
Practice Address - Phone:215-952-9434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-20
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD442053207R00000X
PAMT193006207R00000X
PAMD442218208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102596637Medicaid
PA102596637Medicaid