Basic Information
| Provider Information | |||||||||
| NPI: | 1154483402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAWLIK | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 N GRAHAM ST | ||||||||
| Address2: | SUITE 265 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972272000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032827002 | ||||||||
| FaxNumber: | 5032801290 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 N GRAHAM ST | ||||||||
| Address2: | SUITE 265 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972272000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032827002 | ||||||||
| FaxNumber: | 5032801290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 07/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 036103541 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | MD27961 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 218504 | 05 | OR | MEDICAID |