Provider Demographics
NPI:1518410745
Name:PAVELL, MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PAVELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 PRENTISS DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-2894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5406 W 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2918
Practice Address - Country:US
Practice Address - Phone:219-242-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-23
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003991AB152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist