Provider Demographics
NPI:1679576201
Name:PAVLATOS, ANDREW M (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:M
Last Name:PAVLATOS
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 1:2845 N SHERIDAN RD STE 801
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6159
Mailing Address - Country:US
Mailing Address - Phone:773-665-6851
Mailing Address - Fax:
Practice Address - Street 1:2845 N SHERIDAN RD STE 801
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6159
Practice Address - Country:US
Practice Address - Phone:773-665-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076195207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076195Medicaid
IL036076195Medicaid
IL206556Medicare ID - Type Unspecified