Provider Demographics
NPI:1871552026
Name:PAVLOU, THEOPHANIS A (MD)
Entity type:Individual
Prefix:DR
First Name:THEOPHANIS
Middle Name:A
Last Name:PAVLOU
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 1:200 GRAND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4363
Mailing Address - Country:US
Mailing Address - Phone:201-871-3636
Mailing Address - Fax:201-871-2286
Practice Address - Street 1:200 GRAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4363
Practice Address - Country:US
Practice Address - Phone:201-871-3636
Practice Address - Fax:201-871-2286
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA59211207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6341705Medicaid
736817BFBMedicare ID - Type Unspecified
F52956Medicare UPIN