Provider Demographics
NPI:1245238096
Name:PAVILACK, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:PAVILACK
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 1:3235 ACADEMY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3200
Mailing Address - Country:US
Mailing Address - Phone:757-483-0400
Mailing Address - Fax:
Practice Address - Street 1:3235 ACADEMY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3200
Practice Address - Country:US
Practice Address - Phone:757-483-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232985207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6309909Medicaid
VA1245238096Medicaid
VA247538OtherANTHEM
VA1245238096Medicaid
E87025Medicare UPIN
VA6309909Medicaid