Provider Demographics
NPI:1760457154
Name:PAVLAK, DOUGLAS MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MICHAEL
Last Name:PAVLAK
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:33 SEWALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2603
Practice Address - Country:US
Practice Address - Phone:207-828-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD12077208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1760457154Medicaid
B86345Medicare UPIN
010424957OtherTRICARE
1040126OtherAETNA
250001606OtherMEDICARE RAILROAD
ME285350000Medicaid
002012OtherBCBS
MM0530Medicare ID - Type Unspecified
010424957OtherEMPLOY STANDARDS
M58491OtherCIGNA
010424957OtherSTANDARD TAX ID
010424957OtherCHAMPUS