Provider Demographics
NPI:1447218318
Name:PAVELKA, JEFFREY P (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:P
Last Name:PAVELKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16180 SE SUNNYSIDE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97015-6302
Practice Address - Country:US
Practice Address - Phone:503-582-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO28819207Q00000X
ALDO-757207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500601728Medicaid
AL051510830OtherBCBS
ALG47600Medicare UPIN
AL051510830Medicare ID - Type Unspecified
AL009994750Medicare ID - Type Unspecified
AL051510830OtherBCBS