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General NPI Number Information
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NPI Number | 1235408576
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Entity Type | Organization
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Legal Business Name | TATIANA A PAVLOVA MD
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Dates
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Enumeration Date | 12/15/2011
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Last Update Date | 12/15/2011
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Provider Practice Location Address
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Address Line | 4738 BROADWAY
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City | NEW YORK
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State | NY
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Zip | 10040-1103
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Country | US
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Telephone | 212-569-5331
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Fax | 212-569-5330
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Provider Business Mailing Address
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Address Line | 4738 BROADWAY
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City | NEW YORK
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State | NY
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Zip | 10040-1103
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Country | US
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Telephone | 212-569-5330
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Fax | 212-569-5331
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. TATIANA A PAVLOVA
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Credential | MD, PHD
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Telephone | 212-569-5330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 224668
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License Number State | NY
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