Provider Demographics
NPI:1831262559
Name:PRVULOVIC, TOMI T (MD)
Entity type:Individual
Prefix:DR
First Name:TOMI
Middle Name:T
Last Name:PRVULOVIC
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 4
Mailing Address - Street 2:
Mailing Address - City:CEDAR KNOLLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07927-0004
Mailing Address - Country:US
Mailing Address - Phone:973-865-5111
Mailing Address - Fax:201-939-1701
Practice Address - Street 1:197 RIDGEDALE AVE
Practice Address - Street 2:SUITE 101-C
Practice Address - City:CEDAR KNOLLS
Practice Address - State:NJ
Practice Address - Zip Code:07927-2111
Practice Address - Country:US
Practice Address - Phone:973-865-5111
Practice Address - Fax:973-292-0772
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06129800207LP2900X
NY206029207LP2900X, 208VP0014X
NJ26MA06129800208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100023622Medicare PIN
NJ171175Medicare PIN
NJ6372250002Medicare NSC