Provider Demographics
NPI:1194771204
Name:PAVULURI, PUSHPA (MD)
Entity type:Individual
Prefix:
First Name:PUSHPA
Middle Name:
Last Name:PAVULURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4917 DIXIE HWY STE E
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2565
Practice Address - Country:US
Practice Address - Phone:502-414-5043
Practice Address - Fax:877-243-0175
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36739207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00307134OtherRR MEDICARE
KY64101884Medicaid
KY0609046Medicare Oscar/Certification
KY64101884Medicaid