Provider Demographics
NPI:1093861171
Name:PAVEGLIO, ANTHONY JAMES (OD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JAMES
Last Name:PAVEGLIO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 MACOMB
Mailing Address - Street 2:
Mailing Address - City:MT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:586-464-1472
Practice Address - Street 1:52799 HAYS RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315
Practice Address - Country:US
Practice Address - Phone:586-247-2652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944500196Medicaid
U50772Medicare UPIN