Provider Demographics
NPI:1255360020
Name:PAVULURI, SRINIVAS (MD)
Entity type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:
Last Name:PAVULURI
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: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:732-264-4300
Mailing Address - Fax:732-264-1102
Practice Address - Street 1:1 BETHANY RD STE 91
Practice Address - Street 2:
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-1669
Practice Address - Country:US
Practice Address - Phone:732-264-4300
Practice Address - Fax:732-264-1102
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA073415002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8779805Medicaid
NJ8779805Medicaid
NJH32880Medicare UPIN