Provider Demographics
NPI:1982604641
Name:PAVEGLIO, KATHLEEN A (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:PAVEGLIO
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:PO BOX 3356
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92085-3356
Mailing Address - Country:US
Mailing Address - Phone:760-672-4995
Mailing Address - Fax:760-867-2495
Practice Address - Street 1:4002 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4506
Practice Address - Country:US
Practice Address - Phone:760-473-7969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48106207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
060012306OtherRAILROAD MEDICARE
CAGR0029770Medicaid
060011073OtherRAILROAD MEDICARE
W10585Medicare PIN
HW10585Medicare PIN
060011073OtherRAILROAD MEDICARE