Healthcare Provider Details

I. General information

NPI: 1619952439
Provider Name (Legal Business Name): STEPHAN PAVLOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 EASTERN SHORE DR
SALISBURY MD
21804-5565
US

IV. Provider business mailing address

400 EASTERN SHORE DR P.O. BOX 49
SALISBURY MD
21804-5565
US

V. Phone/Fax

Practice location:
  • Phone: 410-749-8906
  • Fax: 410-219-5662
Mailing address:
  • Phone: 410-749-8906
  • Fax: 410-219-5662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberD41721
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: