Provider Demographics
NPI:1871643007
Name:MED PAVILION PC
Entity Type:Organization
Organization Name:MED PAVILION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARISELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAVARRETE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-325-1543
Mailing Address - Street 1:220A SW 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:MINERAL WELLS
Mailing Address - State:TX
Mailing Address - Zip Code:76067
Mailing Address - Country:US
Mailing Address - Phone:940-325-1543
Mailing Address - Fax:940-325-2679
Practice Address - Street 1:220A SW 26TH AVE
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067
Practice Address - Country:US
Practice Address - Phone:940-325-1543
Practice Address - Fax:940-325-2679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4552207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
80780YOtherBCBS
TX135150408Medicaid
TX135150406Medicaid
TXTXB158020OtherPTAN
TX135150408Medicaid
80780YOtherBCBS