Provider Demographics
NPI:1912130287
Name:NOOTHETI, PAVAN KUMAR (MD, FAAD)
Entity Type:Individual
Prefix:
First Name:PAVAN
Middle Name:KUMAR
Last Name:NOOTHETI
Suffix:
Gender:M
Credentials:MD, FAAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 STAPLEFORD HALL CT
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-4451
Mailing Address - Country:US
Mailing Address - Phone:858-752-4459
Mailing Address - Fax:
Practice Address - Street 1:4700 BERWYN HOUSE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-2474
Practice Address - Country:US
Practice Address - Phone:858-752-4459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90335207N00000X, 207ND0101X
MDD73150207ND0101X, 207N00000X
DCMD33040207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology