Provider Demographics
NPI:1912966425
Name:PAVAMANI, E. VICTOR (MD)
Entity type:Individual
Prefix:DR
First Name:E.
Middle Name:VICTOR
Last Name:PAVAMANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1600 MEDICAL WAY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2166
Mailing Address - Country:US
Mailing Address - Phone:770-972-7999
Mailing Address - Fax:770-972-9528
Practice Address - Street 1:1600 MEDICAL WAY
Practice Address - Street 2:SUITE 220
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2166
Practice Address - Country:US
Practice Address - Phone:770-972-7999
Practice Address - Fax:770-972-9528
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA018411208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000135616BMedicaid
GA000135616AMedicaid
581411492OtherIRS INDIVIDUAL TAXPAYER #
GAP00393203OtherRR MEDICARE
GA000135616AMedicaid
GA02BDJJSMedicare PIN