Provider Demographics
NPI:1285628420
Name:PAWLIKOWSKI, TINA M (OD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:PAWLIKOWSKI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1280
Mailing Address - Country:US
Mailing Address - Phone:773-520-0992
Mailing Address - Fax:773-520-0992
Practice Address - Street 1:338 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1280
Practice Address - Country:US
Practice Address - Phone:773-520-0992
Practice Address - Fax:740-879-3458
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008944152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008944Medicaid
ILL55545Medicare PIN
IL046008944Medicaid