Healthcare Provider Details

I. General information

NPI: 1639190705
Provider Name (Legal Business Name): SRINIVAS PAVULURI, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BETHANY RD STE 91
HAZLET NJ
07730-1669
US

IV. Provider business mailing address

PO BOX 71
HOLMDEL NJ
07733-0071
US

V. Phone/Fax

Practice location:
  • Phone: 732-264-4300
  • Fax: 732-264-1102
Mailing address:
  • Phone: 732-264-4300
  • Fax: 732-264-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25MA07341500
License Number StateNJ

VIII. Authorized Official

Name: DR. SRINIVAS PAVULURI
Title or Position: PRESIDENT/CEO
Credential:
Phone: 732-264-4300