Provider Demographics
NPI:1790767317
Name:PAVELA, STEPHEN L (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:PAVELA
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 1:800 WEST AVE S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-8806
Mailing Address - Country:US
Mailing Address - Phone:608-791-9886
Mailing Address - Fax:608-791-7851
Practice Address - Street 1:800 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8806
Practice Address - Country:US
Practice Address - Phone:608-791-9886
Practice Address - Fax:608-791-7851
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22489207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B55636Medicare UPIN