Provider Demographics
NPI:1487739579
Name:PAVELOCK, RICHARD M (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:PAVELOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 FINES CREEK DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4441
Mailing Address - Country:US
Mailing Address - Phone:704-838-0516
Mailing Address - Fax:704-838-0565
Practice Address - Street 1:2632 FINES CREEK DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4441
Practice Address - Country:US
Practice Address - Phone:704-838-0516
Practice Address - Fax:704-838-0565
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39460207R00000X, 2084P0005X, 2084A0401X, 207Q00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
No174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00219696OtherRAILROAD MEDICARE
NC8966248Medicaid
NC66248OtherBCBS OF NC
NCP00219696OtherRAILROAD MEDICARE
NC562378189OtherTAX ID NUMBER
NC2152260HMedicare ID - Type UnspecifiedMEDICARE NC