Provider Demographics
NPI:1184937310
Name:PAVELKA, MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:153 HERONDO ST
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-5153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1003 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1641
Practice Address - Country:US
Practice Address - Phone:928-445-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49333207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ924528Medicaid