Provider Demographics
NPI:1831269653
Name:PAVLETIC, KIRK PATRICK (OD)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:PATRICK
Last Name:PAVLETIC
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 1:10739 W 159TH STREET
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-4531
Mailing Address - Country:US
Mailing Address - Phone:708-403-7711
Mailing Address - Fax:708-403-7799
Practice Address - Street 1:10739 W 159TH STREET
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-4531
Practice Address - Country:US
Practice Address - Phone:708-403-7711
Practice Address - Fax:708-403-7799
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007849152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01684602OtherBC/BS
0724280001Medicare NSC
01684602OtherBC/BS
U01920Medicare UPIN