Provider Demographics
NPI:1891936522
Name:PAVLOCK, MAX LOUIS (DO)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:LOUIS
Last Name:PAVLOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-9015
Mailing Address - Country:US
Mailing Address - Phone:419-484-5940
Mailing Address - Fax:419-484-5915
Practice Address - Street 1:1255 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-9015
Practice Address - Country:US
Practice Address - Phone:419-484-5940
Practice Address - Fax:419-484-5915
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO 1068207Q00000X
PAOS014787207Q00000X
OH34.012014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine