Provider Demographics
NPI:1295786978
Name:PASTORE, JOHN VINCENT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:VINCENT
Last Name:PASTORE
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 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-1009
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223318208000000X
SC87253208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000528058003OtherBC/BS
050301000096OtherFIDELIS
051021000000OtherFIDELIS
00026960701OtherUNIVERA
000528058001OtherBC/BS
NY02414482Medicaid
1212816OtherIHA
RA5986Medicare PIN
051021000000OtherFIDELIS
NYG41468Medicare UPIN