Provider Demographics
NPI:1891777413
Name:PAVELOCK, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:PAVELOCK
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 1:116 BUSINESS PARK DRIVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6313
Mailing Address - Country:US
Mailing Address - Phone:315-624-7000
Mailing Address - Fax:315-793-1129
Practice Address - Street 1:116 BUSINESS PARK DRIVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6313
Practice Address - Country:US
Practice Address - Phone:315-624-7000
Practice Address - Fax:315-793-1129
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174776207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01240284Medicaid
NYE94216Medicare UPIN
NY01240284Medicaid