Provider Demographics
NPI:1003841917
Name:PACOLD, VIVIEN (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVIEN
Middle Name:
Last Name:PACOLD
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 1:68100 RAMON RD
Mailing Address - Street 2:C-5
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-3387
Mailing Address - Country:US
Mailing Address - Phone:760-321-6068
Mailing Address - Fax:760-770-6789
Practice Address - Street 1:68100 RAMON RD
Practice Address - Street 2:C-5
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-3387
Practice Address - Country:US
Practice Address - Phone:760-321-6068
Practice Address - Fax:760-770-6789
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52805208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A5280501Medicaid
CA00A528050Medicare ID - Type UnspecifiedPROVIDER NUMBER