Provider Demographics
NPI:1669490157
Name:PAVLIC, LYNN (OD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:PAVLIC
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 1:150 W BEAU ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-4425
Mailing Address - Country:US
Mailing Address - Phone:724-225-4440
Mailing Address - Fax:724-225-5125
Practice Address - Street 1:150 W BEAU ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4425
Practice Address - Country:US
Practice Address - Phone:724-225-4440
Practice Address - Fax:724-225-5125
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE007059T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0015842OtherDORAL
36829OtherDAVIS
396281OtherNVA
PA0012949600001Medicaid
PA07059OtherVBA
0015842OtherDORAL
PA564163Medicare ID - Type Unspecified