Provider Demographics
NPI:1902366370
Name:PAVELKA, JEREMIAH DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:DANIEL
Last Name:PAVELKA
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 1:1744 E EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-5802
Mailing Address - Country:US
Mailing Address - Phone:702-281-7873
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-8840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2023-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT2715207P00000X
390200000X
AZ69466207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty