Provider Demographics
NPI:1790113918
Name:KODAK, PAVLO (MD)
Entity Type:Individual
Prefix:
First Name:PAVLO
Middle Name:
Last Name:KODAK
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 1:3315 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-1820
Mailing Address - Country:US
Mailing Address - Phone:443-509-2734
Mailing Address - Fax:
Practice Address - Street 1:3315 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1820
Practice Address - Country:US
Practice Address - Phone:443-509-2734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-25
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9656207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine