Basic Information
Provider Information | |||||||||
NPI: | 1528238805 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAVLOVICH | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 SW 13TH AVE | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972051902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032210161 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9250 SW HALL BLVD | ||||||||
Address2: |   | ||||||||
City: | TIGARD | ||||||||
State: | OR | ||||||||
PostalCode: | 972236857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032930161 | ||||||||
FaxNumber: | 5034523213 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2008 | ||||||||
LastUpdateDate: | 11/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 57.006965 | OH | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207Y00000X | 29320 | OR | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
No ID Information.