Provider Demographics
NPI:1881692341
Name:PAVLINA, PETER M (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:PAVLINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3533 SOUTHERN BLVD
Mailing Address - Street 2:STE 5650
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1264
Mailing Address - Country:US
Mailing Address - Phone:937-294-3611
Mailing Address - Fax:
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:STE 5650
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1264
Practice Address - Country:US
Practice Address - Phone:937-294-3611
Practice Address - Fax:937-294-9010
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058244208G00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0743039Medicaid
OHE30134Medicare UPIN
OH0743039Medicaid