Provider Demographics
NPI:1093755795
Name:PAVLOV, PAUL M (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:PAVLOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15012 LEMOYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-5205
Mailing Address - Country:US
Mailing Address - Phone:228-392-5050
Mailing Address - Fax:229-392-9168
Practice Address - Street 1:15012 LEMOYNE BLVD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-5205
Practice Address - Country:US
Practice Address - Phone:228-392-5050
Practice Address - Fax:229-392-5342
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09593207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000014367Medicaid
MS000014367Medicaid
MS080000162Medicare ID - Type UnspecifiedMEDICARE IND PROV #