Provider Demographics
NPI:1144258765
Name:PAVLISCAK, JILL KATHLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:KATHLEEN
Last Name:PAVLISCAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:575 KELLY ST
Mailing Address - Street 2:
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019-1719
Mailing Address - Country:US
Mailing Address - Phone:650-560-0216
Mailing Address - Fax:650-295-0397
Practice Address - Street 1:575 KELLY ST
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-1719
Practice Address - Country:US
Practice Address - Phone:650-560-0216
Practice Address - Fax:560-295-0397
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA104908207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3459501Medicaid
NM3459501Medicaid
NM8HC739Medicare ID - Type Unspecified