Provider Demographics
NPI:1528060068
Name:PAVKOVIC, IVAN MARK (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:MARK
Last Name:PAVKOVIC
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 1:410 LAKEVILLE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1101
Mailing Address - Country:US
Mailing Address - Phone:516-465-5255
Mailing Address - Fax:
Practice Address - Street 1:410 LAKEVILLE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1101
Practice Address - Country:US
Practice Address - Phone:516-465-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19840174400000X
NC2008-014462080P0008X
NY2821452080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE04056OtherBLUE CROSS BLUE SHIELD NE
NEF29831Medicare UPIN