Basic Information
| Provider Information | |||||||||
| NPI: | 1871552026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAVLOU | ||||||||
| FirstName: | THEOPHANIS | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 GRAND AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076314363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018713636 | ||||||||
| FaxNumber: | 2018712286 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 GRAND AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076314363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018713636 | ||||||||
| FaxNumber: | 2018712286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 11/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | MA59211 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 6341705 | 05 | NJ | MEDICAID |