Healthcare Provider Details

I. General information

NPI: 1083977342
Provider Name (Legal Business Name): MARY VAJRAVELU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 08/19/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 PENN AVE
PITTSBURGH PA
15224-1334
US

IV. Provider business mailing address

4401 PENN AVE FACULTY PAVILION 6TH FLOOR
PITTSBURGH PA
15224
US

V. Phone/Fax

Practice location:
  • Phone: 412-692-5170
  • Fax:
Mailing address:
  • Phone: 412-692-5170
  • Fax: 412-692-5834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT201169
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberMD454379
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: