Healthcare Provider Details

I. General information

NPI: 1962727354
Provider Name (Legal Business Name): NICHOLAS PAIVANAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 10/26/2024
Certification Date: 10/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 MEDICAL PKWY STE 500
ANNAPOLIS MD
21401-3268
US

IV. Provider business mailing address

2002 MEDICAL PKWY STE 500
ANNAPOLIS MD
21401-3268
US

V. Phone/Fax

Practice location:
  • Phone: 410-573-6480
  • Fax: 410-573-9413
Mailing address:
  • Phone: 410-573-6480
  • Fax: 410-573-9413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD83010
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: