Provider Demographics
NPI:1336256486
Name:PAVLATOS, THALES N (MD)
Entity Type:Individual
Prefix:
First Name:THALES
Middle Name:N
Last Name:PAVLATOS
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:PO BOX 632621
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2621
Mailing Address - Country:US
Mailing Address - Phone:706-650-0705
Mailing Address - Fax:706-650-1034
Practice Address - Street 1:100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-1312
Practice Address - Country:US
Practice Address - Phone:937-521-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051485P207L00000X
OH35051485207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0598698Medicaid
0626971Medicare ID - Type Unspecified
OH0598698Medicaid