Provider Demographics
NPI:1154483402
Name:PAWLIK, THEODORE DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:DAVID
Last Name:PAWLIK
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 1:501 N GRAHAM ST
Mailing Address - Street 2:SUITE 265
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-2000
Mailing Address - Country:US
Mailing Address - Phone:503-282-7002
Mailing Address - Fax:503-280-1290
Practice Address - Street 1:501 N GRAHAM ST
Practice Address - Street 2:SUITE 265
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-2000
Practice Address - Country:US
Practice Address - Phone:503-282-7002
Practice Address - Fax:503-280-1290
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361035412080N0001X
ORMD279612080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218504Medicaid