Provider Demographics
NPI:1306057914
Name:PAVULURI, ANURADHA (MD)
Entity type:Individual
Prefix:DR
First Name:ANURADHA
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 1:2490 RIVERSIDE DR
Mailing Address - Street 2:STE B
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1787
Mailing Address - Country:US
Mailing Address - Phone:478-633-6633
Mailing Address - Fax:478-633-4295
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:MSC 10
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-7140
Practice Address - Fax:478-633-4295
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYABO 797 603208000000X
MI4301094423208000000X
GA070401208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1046519OtherMCLAREN
MI200000021987OtherPHP COMMERCIAL
MI1046518OtherMCLAREN
GA070401OtherGA LICENSE
MI3502900092OtherBCBSM