Basic Information
| Provider Information | |||||||||
| NPI: | 1083977342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAJRAVELU | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 PENN AVE | ||||||||
| Address2: | FACULTY PAVILION 6TH FLOOR | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126925170 | ||||||||
| FaxNumber: | 4126925834 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 PENN AVE | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152241334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126925170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2012 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MT201169 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0205X | MD454379 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 1034873410002 | 05 | PA | MEDICAID |