Provider Demographics
NPI:1508815036
Name:PAVLIC, ROMEO ANTON (MD)
Entity Type:Individual
Prefix:
First Name:ROMEO
Middle Name:ANTON
Last Name:PAVLIC
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:PO BOX 637
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210-0637
Mailing Address - Country:US
Mailing Address - Phone:509-557-7776
Mailing Address - Fax:509-838-9683
Practice Address - Street 1:140 S ARTHUR ST STE 408
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2220
Practice Address - Country:US
Practice Address - Phone:509-557-7776
Practice Address - Fax:509-838-9683
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4759207RC0000X
WA00018454207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003876300Medicaid
WA1788009Medicaid
ID003876300Medicaid
WA1788009Medicaid
WAG8874839Medicare PIN