Provider Demographics
NPI:1285794362
Name:PAVLOVIC, TATJANA K (MD)
Entity type:Individual
Prefix:DR
First Name:TATJANA
Middle Name:K
Last Name:PAVLOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2719 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3919
Mailing Address - Country:US
Mailing Address - Phone:773-271-2719
Mailing Address - Fax:
Practice Address - Street 1:2719 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3919
Practice Address - Country:US
Practice Address - Phone:773-271-2719
Practice Address - Fax:773-271-9994
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062416156FX1100X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363313307OtherCOMMERCIAL
IL036062416Medicaid
722020OtherFORCE MATCH
IL036062416Medicaid
IL1285794362Medicare NSC
IL363313307OtherCOMMERCIAL