Basic Information
| Provider Information | |||||||||
| NPI: | 1285138347 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IVAN NOE PAWLOWICZ MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3314 CELEBRATION WAY | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055192 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032123105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2018 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | PAWLOWICZ | ||||||||
| AuthorizedOfficialFirstName: | IVAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9033310506 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N1829 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | N1829 | 01 | TX | TEXAS MEDICAL LICENSE | OTHER |